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Background During the first wave of the coronavirus disease 2019 (COVID-19) pandemic, older patients had an increased risk of hospitalisation and death. Reports on the association of frailty with poor outcome have been conflicting. Objective The aim of the present study was to investigate the independent association between frailty and in-hospital mortality in older hospitalised COVID-19 patients in the Netherlands. Methods This was a multicentre retrospective cohort study in 15 hospitals in the Netherlands, including all patients aged ≥70 years, who were hospitalised with clinically confirmed COVID-19 between February and May 2020. Data were collected on demographics, co-morbidity, disease severity and Clinical Frailty Scale (CFS). Primary outcome was in-hospital mortality. Results A total of 1,376 patients were included (median age 78 years (interquartile range 74–84), 60% male). In total, 499 (38%) patients died during hospital admission. Parameters indicating presence of frailty (CFS 6–9) were associated with more co-morbidities, shorter symptom duration upon presentation (median 4 versus 7 days), lower oxygen demand and lower levels of C-reactive protein. In multivariable analyses, the CFS was independently associated with in-hospital mortality: compared with patients with CFS 1–3, patients with CFS 4–5 had a two times higher risk (odds ratio (OR) 2.0 (95% confidence interval (CI) 1.3–3.0)) and patients with CFS 6–9 had a three times higher risk of in-hospital mortality (OR 2.8 (95% CI 1.8–4.3)). Conclusions The in-hospital mortality of older hospitalised COVID-19 patients in the Netherlands was 38%. Frailty was independently associated with higher in-hospital mortality, even though COVID-19 patients with frailty presented earlier to the hospital with less severe symptoms.

Background We aimed to explore clinicians’ communication, including the discussion of diagnosis, cause, prognosis and care planning, in routine post-diagnostic testing consultations with patients with Mild Cognitive Impairment (MCI). Methods Thematic content analysis was used to analyze audiotaped consultations in which 10 clinicians (eight neurologists and two geriatricians) from 7 memory clinics, disclosed diagnostic information to 13 MCI patients and their care partners. We assessed clinician-patient communication regarding diagnostic label, cause, prognosis and care planning to identify core findings. Results Core findings were: clinicians 1) differed in how they informed about the MCI label; 2) tentatively addressed cause of symptoms; 3) (implicitly) steered against further biomarker testing; 4) rarely informed about the patient’s risk of developing dementia; 5) often informed about the expected course of symptoms emphasizing potential symptom stabilization and/ or improvement, and; 6) did not engage in a conversation on long-term (care) planning. Discussion Clinicians’ information provision about the underlying cause, prognosis and implications for long-term (care) planning in MCI could be more specific. Since most patients and care partners have a strong need to understand the patient’s symptoms, and for information on the prognosis and implications for the future, clinicians’ current approach may not match with those needs.

IntroductionIn an attempt to capture clinically meaningful cognitive decline in early dementia, we developed the Cognitive-Functional Composite (CFC). We investigated the CFC’s sensitivity to decline in comparison to traditional clinical endpoints.MethodsThis longitudinal construct validation study included 148 participants with subjective cognitive decline, mild cognitive impairment or mild dementia. The CFC and traditional tests were administered at baseline, 3, 6 and 12 months. Sensitivity to change was investigated using linear mixed models andr2effect-sizes.ResultsCFC scores declined over time (β=−.16,p<.001), with steepest decline observed in mild Alzheimer’s dementia (β=−.25,p<.001). The CFC showed medium-to-large effect-sizes at succeeding follow-up points (r2=.08–.42), exhibiting greater change than the Clinical Dementia Rating scale (r2=.02–.12). Moreover, change on the CFC was significantly associated with informant reports of cognitive decline (β=.38,pDiscussionBy showing sensitivity to decline, the CFC could enhance the monitoring of disease progression in dementia research and clinical practice.

Background The cognitive-functional composite (CFC) was designed to improve the measurement of clinically relevant changes in predementia and early dementia stages. We have previously demonstrated its good test-retest reliability and feasibility of use. The current study aimed to evaluate several quality aspects of the CFC, including construct validity, clinical relevance, and suitability for the target population. Methods Baseline data of the Capturing Changes in Cognition study was used: an international, prospective cohort study including participants with subjective cognitive decline (SCD), mild cognitive impairment (MCI), Alzheimer’s disease (AD) dementia, and dementia with Lewy bodies (DLB). The CFC comprises seven existing cognitive tests focusing on memory and executive functions (EF) and the informant-based Amsterdam Instrumental Activities of Daily Living Questionnaire (A-IADL-Q). Construct validity and clinical relevance were assessed by (1) confirmatory factor analyses (CFA) using all CFC subtests and (2) linear regression analyses relating the CFC score (independent) to reference measures of disease severity (dependent), correcting for age, sex, and education. To assess the suitability for the target population, we compared score distributions of the CFC to those of traditional tests (Alzheimer’s Disease Assessment Scale–Cognitive subscale, Alzheimer’s Disease Cooperative Study–Activities of Daily Living scale, and Clinical Dementia Rating scale). Results A total of 184 participants were included (age 71.8 ± 8.4; 42% female; n = 14 SCD, n = 80 MCI, n = 78 AD, and n = 12 DLB). CFA showed that the hypothesized three-factor model (memory, EF, and IADL) had adequate fit (CFI = .931, RMSEA = .091, SRMR = .06). Moreover, worse CFC performance was associated with more cognitive decline as reported by the informant (β = .61, p

Introduction: Based on the research of professor Porter Harvard value-based Health care is a framework for restructuring health cate systems with the overarching goal of value for patients – not access, cost-containment, convenience or customer service. It is outcome based. The International center of health outcomes ICHOM is a leading initiative for constructing evidence based methods to evaluate patient based outcomes. Practice change: In the region of our hospital we decided to put this into practice for elderly patients with a hip-fracture. There is no ICHOM program for elderly patients with hip-fractures so we concentrated on the program for frail elderly in combination with the Dutch hip-fracture audit. Based on these values we analyzed data from previous years and contracted “mirror-talks” with patients and their caregivers. Targeted population: frail elderly patients with a hip fracture Aim and theory: We divided the hip-fracture pathway into 3 major steps 1- The patient before the fracture, vulnerable at home or in the nursing home with all kind of problems e.g. polypharmacy, comorbidity, cognitive disorders, and ADL dysfunction and unknown wishes regarding to treatment restrictions and rehabilitations institutions. We developed a leaflet for all the frail elderly in our region to store at home. 2- Intra hospital: from the ambulance, to 3- The start of rehabilitation in a center or at home. Highlights and timeline: From this information we used 6 values for outcome improvement for the coming 12 months; mortality, morbidity, delirium, length and costs of hospital stay, length and costs of rehabilitation, and patients experience and satisfaction. The first results will be presented at the congress.

Objective: To study the outcome of delirium in elderly hip surgery patients. Design: Prospective matched controlled cohort study. Hip surgery patients (n = 112) aged 70 years and older, who participated in a controlled clinical trial of haloperidol prophylaxis for delirium, were followed for an average of 30 months after discharge. Patients with a diagnosis of dementia or mild cognitive impairment (MCI) were identified using psychiatric interviews. Proportions of patients with dementia/MCI were compared across patients who had postoperative delirium and selected control patients matched for preoperatively assessed risk factors who had not developed delirium during index hospitalization. Other outcomes were mortality rate and rate of institutionalization. Results: During the follow-up period, 54.9% of delirium patients had died compared to 34.1% of the controls (relative risk = 1.6, 95% CI = 1.0–2.6). Dementia or MCI was diagnosed in 77.8% of the surviving patients with postoperative delirium and in 40.9% of control patients (relative risk = 1.9, 95% CI = 1.1–3.3). Half of the patients with delirium were institutionalized at follow-up compared to 28.6% of the controls (relative risk = 1.8, 95% CI = 0.9–3.4). Conclusion: The risk of dementia or MCI at follow-up is almost doubled in elderly hip surgery patients with postoperative delirium compared with at-risk patients without delirium. Delirium may indicate underlying dementia.

OBJECTIVES: To evaluate risk factors for postoperative delirium in a cohort of elderly hip-surgery patients and to validate a medical risk stratification model. DESIGN: Prospective cohort study. SETTING: Medical school‐affiliated general hospital in Alkmaar, the Netherlands. PARTICIPANTS: Six hundred three hip-surgery patients aged 70 and older screened forrisk factors forpostoperative delirium. MEASUREMENTS: Predefined risk factors for delirium were assessed on admission. One point was assigned for each of four risk factors present, resulting in three groups: low, intermediate, and high risk. Baseline screening and assessment included the Mini-Mental State Examination, the standardized Snellen test for visual impairment, chart review to determine Acute Physiological and Chronic Health Evaluation II score, and blood urea nitrogen to creatinine ratio. The primary outcome was postoperative delirium, as defined using Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, and Confusion Assessment Method criteria. All patients were screened daily fordelirium. RESULTS: Incidence of delirium was 3.8% in the low-risk group (Po.001), 11.1% in the intermediate-risk group (P 5.27, relative risk (RR) 53.0), and 37.1% in the highrisk group (Po.001, RR 59.8). Cognitive impairment at admission hadthe highestpredictive valueforpostoperative delirium (coefficient of determination 50.15). Contrary to previous findings, age was an independent predictive factor for delirium. Moreover, postoperative delirium was four times as frequent in acute patients as in elective hipreplacement patients. CONCLUSION: The medical risk factor model is valid for elderly hip-surgery patients. Cognitive impairment, age, and type of admission are important risk factors for delirium in this surgical population. J Am Geriatr Soc 54:817–822, 2006.

OBJECTIVES: To study the effectiveness of haloperidol prophylaxis on incidence, severity, and duration of postoperative delirium in elderly hip-surgery patients at risk for delirium. DESIGN: Randomized, double-blind, placebo-controlled trial. SETTING: Large medical school–affiliated general hospital in Alkmaar, the Netherlands. PARTICIPANTS: A total of 430 hip-surgery patients aged 70 and older at risk for postoperative delirium. INTERVENTION: Haloperidol 1.5 mg/d or placebo was started preoperatively and continued for up to 3 days postoperatively. Proactive geriatric consultation was provided for all randomized patients. MEASUREMENTS: The primary outcome was the incidence of postoperative delirium (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, and Confusion Assessment Method criteria). Secondary outcomes were the severity of delirium (Delirium Rating Scale, revised version-98 (DRS-R-98)), the duration of delirium, and the length of hospital stay. RESULTS: The overall incidence of postoperative delirium was 15.8%. The percentage of patients with postoperative delirium in the haloperidol and placebo treatment condition was 15.1% and 16.5%, respectively (relative risk 5 0.91, 95% confidence interval (CI) 5 0.6–1.3); the

Objective Pathophysiological mechanisms leading to delirium are not clear. Age is a known risk factor and hypothesised to be accompanied by a low-grade inflammatory state. Previous studies have shown an association between delirium and circulating proinflammatory markers in acutely ill and postoperative patients. In light of the ageing/inflammation theory, we investigated the association of these markers with delirium in not acutely ill, elderly patients. Methods In a prospective nested case-control study levels of C-reactive protein (CRP), interleukin 6 (Il-6), insulin growth factor 1 (IGF-1) were measured pre-operatively in elderly patients admitted for hip-surgery. These levels were compared between patients who later developed a post-operative delirium and patients who did not. Patients were matched for age and disease severity. Results Eighteen patients who developed delirium post-operatively were matched with 50 controls. Median APACHE-scores were below 16 in both groups. Pre-operative serum concentrations of CRP, Il-6 and IGF-1 did not differ between groups. IL-6 levels were associated with a measure of cognitive impairment. Conclusion In the present study no relationship was found between levels of pre-operative circulating pro-inflammatory markers and post-operative delirium in elderly patients, who were free from acute or severe disease. Copyright © 2008 John Wiley & Sons, Ltd.

Delirium is the most important neuro-psychiatric problem among elderly admitted to general hospitals. With an average incidence above 25% and increasing to almost 90% in the ICUpopulation. It is a serious andpotentiallypreventablemental condition. It is therefore important to recognise patients at risk for delirium on admittance to the hospital, so primary preventive programs can be started. Manyof the risk factors arewell-known,bothpredisposingandprecipitating factors. Some of these risk factors have been combined to make predictive models for delirium. Much further work is needed to determine and examine specific risk factors and their value in models for the prediction of delirium in different patient groups. Based on recent knowledge on predisposing and precipitating risk factors for delirium, interventions have been proposed to influence the detrimental effects of these factors and thus prevent (primary prevention) or to reduce its duration and severity (secondary prevention). Relatively few interventions have been evaluated and supported by good quality clinical trials. Some of the trials support multicomponent intervention strategies consisting of nursing, medical and sometimes pharmacological components. In this symposium we will provide the latest data on riskassessment, targeting patients at risk and existing models for prevention of delirium. We will show the work we did on the development of a very simple and highly effective Delirium Risk Assessment Score model (DRAS) and show the data on its use in different patient groups (surgical, cardiology and stroke) and the positive effect of a multicomponent intervention program, after identifying risk patients, on incidence, duration and severity of delirium.

Delirium in the ICU can compromise the recovery process, prolong the ICU and hospital stays and increase mortality. Therefore, recognition of delirium is of utmost importance.