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Introduction Delirium is frequently multifactorial, and causes are often missed in clinical practice. The Aetiology in Delirium - Diagnostic Support Tool (AiD-DST) was developed to improve recognition of the causes. We undertook an evaluation of an electronic version of AiD-DST. Methods A development and evaluation life cycle of improvement was used. In phase 1, alpha testing among the development group evaluated technical performance of AiD-DST. In phase 2, we performed a cycle of beta testing among junior doctors to assess impressions of AiD-DST using Think Aloud methodology. We grouped responses into themes and made changes to AiD-DST by the development group accordingly. In phase 3, usability and acceptance of AiD-DST was assessed using the mHealth App Usability Questionnaire (MAUQ). Results In phase 1, software issues were identified, and modifications made. In phase 2, feedback was obtained from 29 junior doctors. Three cycles of feedback were obtained. The number of items identified after each cycle were 20, 12 and 7, respectively. Content was grouped into themes of; ‘style and grammar’, ‘formatting’, ‘IT’, ‘missed diagnosis’ and ‘other concerns.’ In phase 3, 20 participants completed MAUQ questionnaire. Overall, the average score was 6.36 (SD=0.8) with 7 as the highest attainable score. This translates to agreement up to strong agreement concerning usability of AiD-DST. Conclusion After a process of optimisation, AiD-DST has been shown to be a usable and potentially useful diagnostic support tool to help junior doctors identify cause(s) of delirium. An implementation study is planned.

© 2020 American Psychological Association. Dreams and daydreams are as beguiling as they are intangible. Both share many features, from neurobiology to the sensed experience. Nevertheless, the specific narrative relationship between both, if any, remains uncertain. Theories of dream origins are many: from the psychodynamic royal road, to biological theories including Hebbian-based memory consolidation and a unified quantum brain theory that extends to waking and dreaming alike. Both the ephemeral nature of dreams, and an inability to simultaneously study their content and biology, renders them difficult to research from a conventional biomedical perspective. This leaves agreement on the fundamental properties of dreams as ambiguous, and even the state of consciousness enjoyed during sleep is contested. What is known is that the qualia and neurophysiological signature of dreams and daydreaming share many features. We propose further, from a subjective experientialist position, that dream content is specifically derived from daydreaming or mindful wandering (subserved by the default mode network). If substantiated, this concept offers a new insight into the origin of dreams.

Dysfunction of the cholinergic basal forebrain (BF) neurotransmitter system, including cholinergic axon denervation of the cortex, plays an important role in cognitive decline and dementia. A validated method to directly quantify cortical cholinergic terminal integrity enables exploration of the involvement of this system in diverse cognitive profiles associated with dementia, particularly at a prodromal stage. In this study, we used the radiotracer [

Le délirium est un problème de santé majeur aux conséquences potentiellement graves. Malheureusement, la prise en charge de ce trouble est souvent sous-optimale. Nous considérons que les lacunes dans les soins offerts aux patients avec délirium sont liées aux particularités de cette condition, qui affecte la perception du « soi » de la personne qui en souffre. Cette atteinte entraîne un comportement hors de contrôle chez la personne avec délirium et l'expose à une déshumanisation mécaniste. Une solution consisterait à favoriser une vision élargie du « soi », inspirée de la philosophie et des sciences cognitives récentes, afin d'aider les cliniciens dans la compréhension du comportement pathologique en tant que manifestation de la perturbation de la pensée. Une approche centrée sur l'éthique des soins, intégrant un nouveau cadre pour la relation patient-soignant, est proposée. Considérées dans leur ensemble, les propositions novatrices émises pourraient faciliter l'élaboration d'un cadre de pratiques et de relations plus attentionnées et plus efficaces pour le traitement du délirium.Delirium is a major health care problem with potentially serious consequences. Sub-optimal management is an unfortunate but pervasive hallmark of the disorder. We argue that lapses in the care of delirious patients are related to the peculiarities of delirium as a disorder that affects the “self” of the sufferer. Therefore, corruption of self renders behaviour outside the control of the delirious individual and places the person at risk of mechanistic dehumanisation. A proposed solution is to foster an expanded view of the self, taken from recent philosophy and cognitive science, which would allow the clinician to understand pathological behaviour as indicative of disruption to thought. An ethics of care approach that reframes the patient/carer relationship is proposed. These unique propositions could, together, facilitate the development of a framework of more caring and effective practices and relationships for delirium treatment.

Background Persons with dementia commonly experience a range of behavioural and psychological symptoms, including agitation, aggression, perceptual disturbances, and depression. While psychotropic medications are regularly prescribed to mitigate these symptoms, these agents also carry a broad adverse effect profile. This study aimed to characterize psychotropic medication use in patients with dementia, as well as identify prescribing factors associated with falls in this cohort. Methods This retrospective study collected longitudinal demographic and medication data from all patients admitted to a neuro‐cognitive unit at an Australian metropolitan hospital over a 2‐year period. Psychotropic polypharmacy and psychotropic agent use per patient‐fortnight were investigated for their association with inpatient falls. Results All patients (n = 147) were prescribed at least one psychotropic medication, with 96% receiving anti‐psychotic medications and 90% receiving benzodiazepines. Patient fall rate was significantly associated with anticholinergic drug use (Incidence rate ratio: 2.2; P, Patients with dementia are often prescribed psychotropic medications, including antipsychotics and benzodiazepines, to relieve the behavioural and psychological symptoms of dementia. However, this must be counterbalanced against psychotropic adverse effects. Our study demonstrates that anticholinergic medications and psychotropic polypharmacy are associated with fall incidence in patients with dementia.

Delirium is a common disorder in hospitalized older adults and the defining characteristic is a disturbance of consciousness. Unfortunately, there are currently no testable measures of consciousness as pertains to its disruption in delirium. Not surprisingly rates of recognition of delirium suffer. Arguably, a greater understanding of the quantum of consciousness may improve delirium diagnosis through better diagnostic tools. Candidate dimensions of consciousness derived from fields of psychology, psychiatry, and philosophy are discussed and relevance to delirium explored. Based upon existing literature in the field of consciousness we identify the pre-reflective state, experiential awareness, and functional networks as candidate sites that may be affected in delirium. Opportunities for clinical instrument development and how these tools can be tested are discussed. We conclude that consciousness content may not hold to a unitary measurement, but facets of its integrity that are impacted in delirium are open to further exploration. Disorders in pre-reflective status, experiential awareness, and functional networks may represent the measurable "rabbit holes" of consciousness disturbance.

Delirium, a common complication of an intensive care unit (ICU) admission, is inconsistently diagnosed by clinicians. Current screening tools require specialist expertise and/or training. Some are time-consuming to administer, and reliability in routine clinical practice is questionable. An innovative app designed to enable efficient and sensitive screening for delirium without specialist training (eDIS-ICU) has recently been described. This pilot study compared the eDIS-ICU against the reference standard expert assessment using DSM-V (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition) criteria and the Confusion Assessment Method for the ICU (CAM-ICU).In this prospective, single-centre pilot study, a convenience sample of 29 ICU patients were recruited at a tertiary referral hospital between November 2018 and August 2019. After obtaining written consent, demographic and clinical data were collected, and the patients were screened for delirium using eDIS-ICU and CAM-ICU by two clinician researchers in random order. The patients were also assessed for presence of delirium independently by an expert clinician using a structured interview to diagnose as per DSM-V criteria. The results of screening and diagnosis were tabulated to allow comparison of screening tools against diagnosis; sensitivity and specificity of the tools were calculated.Seven participants were diagnosed with delirium as per DSM-V criteria. The eDIS-ICU tool correctly identified six of these participants compared with two identified by CAM-ICU. The sensitivity of the eDIS-ICU tool was 86% (95% confidence interval [CI] = 81.5-100.0) compared with 29% (95% CI = 5.1-69.7) for CAM-ICU (p 0.05), and the specificity was 73% (95% CI = 81.5-100.0) versus 96% (95% CI = 75.1-99.8), respectively.The simple and novel eDIS-ICU delirium screening tool was noninferior to the CAM-ICU in detecting delirium as per DSM-V criteria. A definitive validation study is warranted.

Background recognition of the multifactorial causes of delirium represents a clinical challenge. Objectives to develop and show proof of principle of a diagnostic support tool (DST) for identification of causes of delirium. Methods stage 1—development of the aetiology in delirium-diagnostic support tool (AiD-DST); stage 2—validation of the AiD-DST against reference standard diagnosis, based on clinical assessment from two independent consultant geriatricians. Results a series of eight steps AiD-DST were formulated by an expert group to identify possible causes of delirium. Forty inpatients admitted to a general medical unit with a consultant physician/geriatrician diagnosis of delirium were recruited, consented and reviewed against the AiD-DST. Mean age was 85.1 (standard deviation 7.9) years and 26 (65%) of participants were female. Participants had multiple chronic co-morbidities [median Charlson Comorbidity Index 7; interquartile range (IQR 6–9)] and median number of medications was 8 (IQR 6–11.75). Median number of causes of delirium detected on AiD-DST was 3 (IQR 3–4) versus 5 (IQR 3–6) using the reference standard diagnosis, with sensitivity of 88.8% (95% confidence interval, 81.6–93.9%) and specificity of 71.8% (63–79.5%). Conclusions the aetiology in delirium DST shows promise in the identification of cause(s) in delirium.

Delirium is conceptually elusive and falls outside of conventional biomedical models. Positivist theoretical paradigms of single linear causality are therefore insufficient to provide mechanistic enlightenment. Delirium does, however, share parallels with features of failure within a complex system. Lessons from complex system theory provide important potential healthcare dividends with respect to delirium. The brain is complex and exhibits emergence, a feature of consciousness, which is crucially impacted in delirium. Volatility, non-linear relationships and multiple point failures are cardinal features of complex system failure, thence delirium. An alternative emphasis away from end of chain analysis and oversimplification of cause and an attempt to avoid introduction of new forms of failure in a responsive healthcare environment are lessons from complex system theory. Insights from complex systems provide potentially important mechanistic underpinnings and new lines of research enquiry for delirium. Not least, a fuller understanding of delirium from a complex system viewpoint may help transform management and outcomes in one of the biggest challenges of acute healthcare.

Objectives Implementation research into delirium care is lacking. Exploiting known practice barriers to understand what management strategies work best in delirium is a means of prioritising care interventions. A consensus approach to determining priority interventions in delirium was derived and related to reference standards in health-care practice. Methods A workshop of 20 experts was held at the Australasian Delirium Association conference 2016. Structured small group work, iterative ranking and a 21-member check were undertaken to (i) explore research barriers in delirium care; (ii) explore how barriers related to individual items of multicomponent interventions; and (iii) rank multicomponent interventions in relation to each statement within the newly released Australian Commission on Safety and Quality in Health Care delirium standard. Results Top-ranking interventions included the following: education and training, comprehensive geriatric assessment, family partnerships, individualised care and multidisciplinary engagement. Conclusion Delirium experts identified a minimum standard of any care intervention for delirium.

Objective To evaluate the safety (mortality and readmissions) and efficiency (length of stay) of the hospital-in-the-home delirium pathway (THDP) compared with hospital-based care. Methods Patients admitted to THDP were compared against an age-matched cohort of patients with delirium managed entirely in hospital. Outcome data were obtained through retrospective chart review, and hospital coding was used to identify controls. Results Ninety-six patients were included in this study, of which 46 were managed on THDP. There was a significant frailty and co-morbidity burden with no differences in the demographic profile between groups. Inpatient length of stay was shorter on THDP (THDP mean 8 days, control 11 days; P = .02). One-month mortality was 13% in THDP compared with 24% in the control group (P = .2). One-month readmission was 30% in THDP and 18% in the control group (P = .23). Conclusion The hospital-in-the-home delirium pathway is a promising alternative to in-hospital delirium care for selected patients.

How to Obtain Contact Hours by Reading This Article Instructions 1.2 contact hours will be awarded by Villanova University College of Nursing upon successful completion of this activity. A contact hour is a unit of measurement that denotes 60 minutes of an organized learning activity. This is a learner-based activity. Villanova University College of Nursing does not require submission of your answers to the quiz. A contact hour certificate will be awarded once you register, pay the registration fee, and complete the evaluation form online at http://goo.gl/gMfXaf . To obtain contact hours you must: 1. Read the article, “Associations Between Dehydration, Cognitive Impairment, and Frailty in Older Hospitalized Patients: An Exploratory Study” found on pages 19–27, carefully noting any tables and other illustrative materials that are included to enhance your knowledge and understanding of the content. Be sure to keep track of the amount of time (number of minutes) you spend reading the article and completing the quiz. 2. Read and answer each question on the quiz. After completing all of the questions, compare your answers to those provided within this issue. If you have incorrect answers, return to the article for further study. 3. Go to the Villanova website listed above to register for contact hour credit. You will be asked to provide your name; contact information; and a VISA, MasterCard, or Discover card number for payment of the $20.00 fee. Once you complete the online evaluation, a certificate will be automatically generated. This activity is valid for continuing education credit until April 30, 2019. Contact Hours This activity is co-provided by Villanova University College of Nursing and SLACK Incorporated. Villanova University College of Nursing is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation. Activity Objectives 1. Describe the incidence of dehydration in older hospitalized patients. 2. Identify risk and management strategies related to dehydration in older hospitalized patients. Disclosure Statement Neither the planners nor the author have any conflicts of interest to disclose. The current exploratory study (a) assessed the prevalence of dehydration in older adults (age ≤60 years) with and without cognitive impairment (CI) admitted to the hospital; and (b) examined associations between dehydration, CI, and frailty. Forty-four patients participated and dehydration was assessed within 24 hours of admission and at Day 4 or discharge (whichever occurred first). Patients' cognitive function and frailty statuses were assessed using validated instruments. Twenty-seven (61%) patients had CI and 61% were frail. Prevalence of dehydration at admission was 29% ( n = 12) and 19% ( n = 6) at study exit, and dehydration status did not differ according to CI or frailty status. However, within the non-CI group, significantly more frail than fit patients were dehydrated at admission ( p = 0.03). Findings indicate dehydration is common among older hospitalized patients and that frailty may increase the risk for dehydration in cognitively intact older adults. [ Journal of Gerontological Nursing , 42 (5), 19–27.]

Background: Clinicians frequently use their own judgement to assess patient’s hydration status although there is limited evidence for the diagnostic utility of any individual clinical symptom. Hence, the aim of this study was to compare the diagnostic accuracy of clinically assessed dehydration in older hospital patients (using multiple symptoms), versus dehydration measured using serum-calculated osmolality (CO) as the reference standard. Method: Participants were 44 hospital patients aged ≥ 60 years. Dehydration was assessed clinically and pathologically (CO) within 24 hours of admission and at study exit. Indicators of diagnostic accuracy were calculated. Results: Clinicians identified 27% of patients as dehydrated at admission, and 19% at exit, compared to 19% and 16% using CO. Agreement between the measures was fair at admission and poor at exit. Clinical assessment showed poor sensitivity for predicting dehydration with reasonable specificity. Conclusions: Compared to the use of CO, clinical assessment of dehydration in older patients was poor. Given that failure to identify dehydration in this population may have serious consequences, we recommend that clinicians do not rely upon their own assessments without also using the reference standard.

Background Departments of Internal Medicine tend to treat patients on a first come first served basis. The effects of using triage systems are not known. Methods We studied a cohort in an Acute Medical Unit (AMU). A computer-assisted triage system using acute physiology, pre-existing illness and mobility identified five distinct risk categories. Management of the category of very low risk patients was streamlined by a dedicated Navigator. Main outcome parameters were length of hospital stay (LOS) and overall costs. Results were adjusted for the degree of frailty as measured by the Clinical Frailty Scale (CFS). A six month baseline phase and intervention phase were compared. Results 6764 patients were included: 3084 in the baseline and 3680 in the intervention phase. Patients with very low risk of death accounted for 40% of the cohort. The LOS of the 1489 patients with very low risk of death in the intervention group was reduced by a mean of 1.85 days if compared with the 1276 patients with very low risk in the baseline cohort. This was true even after adjustment for frailty. Over the six month period the cost of care was reduced by £250,158 in very low patients with no increase in readmissions or 30 day mortality. Conclusions Implementation of an advanced triage system had a measurable impact on cost of care for patients with very low risk of death. Patients were safely discharged earlier to their own home and the intervention was cost-effective.

SummaryDelirium has been associated with institutionalization, increased length of hospital stay, cognitive and functional decline and mortality. Research in the last thirty years has recognized that accurate diagnostic criteria allow for targeted interventions for those suffering from delirium. However, despite the advances made in understanding delirium, adverse outcomes persist.This article will first review how the evolution of diagnostic criteria has fostered improvements in the recognition of delirium and facilitated the development of therapeutic strategies. Second, we discuss how this foundation in approach to delirium has influenced outcomes and the evidence for causality. Finally, the candidate factors responsible for propagating adverse events are considered and future research direction outlined.

Delirium is a temporary condition involving a disturbance in attention, cognition and awareness. Typically, it develops over a relatively short time frame and fluctuates in severity. Delirium is preventable in one‐third of cases, and early detection improves outcomes 1. Yet, this common and potentially devastating hospital complication is associated with non‐detection rates as high as 70% 1, 2. Why is this?

The application of transcatheter aortic valve implantation (TAVI) to high-surgical-risk and inoperable patients with severe aortic stenosis (AS) is gaining widespread acceptance with a burgeoning supportive evidence base.1 The benefits associated with the application of this technique, however, are mitigated by the occurrence of major, disabling stroke with associated increased mortality and early-reduced quality of life.2 Despite this, the risk/benefit ratio has been considered acceptable in appropriately selected patients given the outcomes of alternate management options in these high-risk and inoperable populations.3,4 The incidence of cerebrovascular events (CVEs) subsequent to TAVI exceeds that after any other cardiac intervention or valve surgery, most notably in the acute periprocedural period, diminishing over the subsequent 2 months.5 This elevated early risk reflects the increased incidence of ischemic stroke thought secondary to particulate emboli dislodged by the procedure itself or as a result of thromboembolism.6 In fact, cerebral embolism is a universal finding associated with these procedures.7 Most events, however, are subclinical or silent, with clinically apparent CVEs representing but the tip-of-the-iceberg. As a result of the difficulty ascertaining these subclinical events, the true association between TAVI and neurological injury is unknown and the harm potentially underestimated. This article aims to comprehensively review neurological injury in TAVI, with an emphasis on cerebrovascular disease. Evidence and current concepts regarding pathophysiological mechanisms, risk factors, and prognostic implications will be discussed and risk reduction strategies explored. CVEs post-TAVI are classified based on clinical severity as illustrated in Figure 1. Incomplete reporting and variable definitions of clinically apparent events and disregard of subclinical events have limited the true evaluation of CVEs associated with TAVI. Consequently, in 2011 the Valve Academic Research Consortium published a consensus report on standardized end point definitions, including stroke, which were expanded and refined in …

Delirium is recognised as a disorder of consciousness, however, no evidence has been previously generated to specifically address this premise. In order to evaluate this established notion, we have attempted to review consciousness, the components of consciousness and the emerging evidence for neuroanatomical correlates and then relate this to the recognized features of delirium. We have established that the level of awareness is modulated by alertness and arousal, focused by attention and has the ability to switch between the personal resonances of the experience to the precision of cognition. We have discussed consciousness's relationship with delirium and how the degree of integration of CNS function is mandatory for realisation of higher order function and this has implications for the conceptualisation and management of delirium. We have explored the understanding of downstream, components of consciousness as not giving rise to the full condition of delirium but as a subsyndromal state. We have argued that there is a need for future diagnostic criteria, such as DSM-V, to operationalize disturbance of consciousness together with non-cognitive manifestations of delirium. Intervention studies in delirium have focussed on drugs that improve memory (cholinesterase inhibitors). If memory is only one element of consciousness then we reason instead on evaluating the determinants of consciousness that may be modifiable, such as awareness. Reinforcement of environmental awareness by managing a patient within a low stimulus or familiar surrounding may therefore offer a therapeutic intervention. Overall there seemed support for, or no evidence against, the belief that delirium is a disorder of consciousness. From Descartes 'I think therefore I am' we can say 'I am aware not therefore delirious I am'.

Objective(s): A new model of care for the management of patients with delirium was developed and evaluated. Method: A 4-bedded Close Observation Unit (COU) was introduced. The model comprised an education strategy for assistants in nursing (AIN), environmental adaptations and AIN to patient ratio of 1:4. Outcomes in all patients with delirium before and after introduction of the new model of care were compared. Results: 105 patients were admitted to COU, of whom 100 (95%) were diagnosed with delirium. In-hospital mortality improved after introduction of the unit (15% versus 5%; p=0.002) without significant change in length of stay, discharge destination or falls frequency. Conclusion: A dedicated unit for delirium management within medicine achieved a reduction in mortality.

Background: Consciousness, the medium of sentient thought, requires integrity of functional networks and their connectivity. In health, they function as a co-operative but mutually exclusive paradigm of introspection versus external awareness subserved via the Default Mode Network and Task Positive State, respectively. Higher thinking in the conscious state is then segregated according to need. There is research evidence to suggest that functional networks may be impacted in disorders of consciousness and conceptual support for a mechanistic role in delirium. This potentially central aspect of delirium manifestation is relatively unexplored. Objective: This article describes the role of disrupted functional networks in delirium. How this relates to current understanding of delirium neurobiology and the ramifications for clinical diagnosis is discussed. Method: A review of the role of functional networks, particularly DMN and TPN, has been undertaken with respect to health and delirium. An exploration of how symptoms of delirium may be related to functional network aberrancy has been undertaken. Implications for research and clinical practice in delirium have been presented. Results: In delirium, a disturbance of consciousness, the DMN is pathologically co-activated and functional cortical connectivity is compromised. The clinical correlate is of an experiential singularity where internal and external drivers become indistinguishable, reality and delusion merge and the notion of self is effaced. Our group propose that functional network disruption in conjunction with cortical disconnectivity is central to the mechanism of delirium. Clinical tools may exploit the neurobiology of delirium to improve its diagnosis and an example of such a simple screening instrument (SQeeC) is provided. Conclusion: Functional networks are critically disrupted in delirium and may be central to clinical features. A better understanding of the neurobiology of delirium will generate research opportunities with potential for therapeutic gains in detection, diagnosis, and management.

Background The application of transcatheter aortic valve implantation ( TAVI ) to intermediate‐risk patients is a controversial issue. Of concern, neurological injury in this group remains poorly defined. Among high‐risk and inoperable patients, subclinical injury is reported on average in 75% undergoing the procedure. Although this attendant risk may be acceptable in higher‐risk patients, it may not be so in those of lower risk. Methods and Results Forty patients undergoing TAVI with the Edwards SAPIEN ‐ XT ™ prosthesis were prospectively studied. Patients were of intermediate surgical risk, with a mean±standard deviation Society of Thoracic Surgeons score of 5.1±2.5% and a Euro SCORE II of 4.8±2.4%; participant age was 82±7 years. Clinically apparent injury was assessed by serial National Institutes of Health Stroke Scale assessments, Montreal Cognitive Assessments (Mo CA ), and with the Confusion Assessment Method. These identified 1 (2.5%) minor stroke, 1 (2.5%) episode of postoperative delirium, and 2 patients (5%) with significant postoperative cognitive dysfunction. Subclinical neurological injury was assessed using brain magnetic resonance imaging, including diffusion‐weighted imaging ( DWI ) sequences preprocedure and at 3±1 days postprocedure. This identified 68 new DWI lesions present in 60% of participants, with a median±interquartile range of 1±3 lesions/patient and volumes of infarction of 24±19 μL/lesion and 89±218 μL/patient. DWI lesions were associated with a statistically significant reduction in early cognition (mean ΔMo CA −3.5±1.7) without effect on cognition, quality of life, or functional capacity at 6 months. Conclusions Objectively measured subclinical neurological injuries remain a concern in intermediate‐risk patients undergoing TAVI and are likely to manifest with early neurocognitive changes. Clinical Trial Registration URL : http://www.anzctr.org.au . Australian & New Zealand Clinical Trials Registry: ACTRN 12613000083796.

Background: delirium and frailty are common among hospitalised older people but delirium is often missed and frailty considered difficult to measure in clinical practice. Objective: to explore the relationship between delirium and frailty in older inpatients and determine their impact on survival. Design and setting: the prospective cohort study of 273 patients aged ≥75 years. Measures: patients were screened for delirium at presentation and on alternate days throughout their hospital stay. Frailty status was measured by an index of accumulated deficits (FI), giving a potential score from 0 (no deficits) to 1.0 (all 33 deficits), with 0.25 used as the cut-off between ‘fit’ and ‘frail’. Results: delirium was detected in 102 patients (mean FI: 0.33) and excluded in 171 (mean FI: 0.18) (P < 0.005); 111 patients were frail. Among patients with delirium, the median survival in fit patients was 359 days (95% CI: 118–600) compared with 88 days for those who were frail (95% CI: 5–171; P < 0.05). Conclusion: delirium was associated with higher levels of frailty: the identification of frail patients may help to target those at a greatest risk of delirium. Survival following delirium was poor with the combination of frailty and delirium conferring a particularly bleak prognosis.

Background: multidisciplinary rehabilitation is of proven benefit in the management of older inpatients. However, the identification of patients who will do well with rehabilitation currently lacks a strong evidence base. Objectives: the aims of this study were to compare the importance of chorological age, gender, co-morbidities and frailty in the prediction of adverse outcomes for patients admitted to an acute geriatric rehabilitation ward. Design: prospective observational cohort study. Subjects and setting: two hundred and sixty-five patients admitted consecutively to an acute geriatric rehabilitation ward at a tertiary care teaching hospital. Methods: frailty status was measured by an index of accumulated deficits, giving a potential score from 0 (no deficits) to 1.0 (all 40 deficits present). Patients were stratified into three outcomes: good (discharged to original residence within 28 days), intermediate (discharged to original residence but longer hospital stay) and poor (newly institutionalised or died). Results: patients were old (82.6 ± 8.6 years) and frail (mean frailty index (FI) 0.34 ± 0.09). Frailty status correlated significantly with length of stay and was a predictor of poor functional gain. The odds ratio of intermediate and poor outcome relative to a good outcome was 4.95 (95% CI = 3.21, 7.59; P < 0.001) per unit increase in FI. Chronological age, gender and co-morbidity showed no significant association with outcomes. Conclusion: frailty is associated with adverse rehabilitation outcomes. The FI may have clinical utility, augmenting clinical judgement in the management of older inpatients.

Delirium is a commonly occurring complex neuropsychiatric disorder. Evidence for its treatment based on randomized controlled trials is poor. The aim of this study is to determine the efficacy and acceptability of quetiapine in the treatment of delirium.

While dehydration is common in older patients and is associated with poor outcomes, it has been infrequently studied in the hospital setting. Thus, the aim of this study was to identify potential barriers and enablers to the maintenance of adequate hydration in older patients in an acute hospital environment. An observational study, involving patients aged 60 years and older admitted to an acute care hospital in Queensland, Australia, was undertaken. Forty-four patients were observed during mealtimes, and chart and room audits were performed to identify hydration management strategies, weight records and the presence or absence of fluid balance charts. Results revealed a number of system and practice-related barriers including patient difficulties with opening fluid containers and low levels of documentation of hydration management strategies. Addressing these issues is an important first step towards improving the management of hydration in medically ill older hospital patients.

Background: Management of patients with delirium presents a challenge. Aims: Supported discharge with Hospital in the Home (HITH) for patients with delirium was developed and evaluated. Methods: Patients admitted acutely to internal medicine and geriatrics, with a diagnosis of delirium were considered for HITH. Patients with a full time career and who lived in their own residence were eligible for the program. Delirium was diagnosed using CAM. Outcomes were compared against historical control. All data was collected prospectively. Results: A total of 89 patients (9.2 per cent) were diagnosed with delirium. Of 31 patients eligible for HITH, 17 had suitable carers. Sixteen patient-caregiver teams were successfully discharged on HITH. Age, frailty score, length of stay and readmissions did not vary significantly between the intervention and control group (N=7). Thirteen patient-carers provided feedback and which was supportive of the intervention. Conclusion: This innovative model of care was feasible and well received. Further studies are recommended.

Frailty represents a state of heightened vulnerability. Mobility impairment contributes to the construct of frailty and channels adverse events. While mobility disorder is universal at a high burden of frailty, neither mobility nor balance dysfunction is sufficient to fully define frailty. Frailty represents proximity to complex system failure, with higher-order disturbance, such as mobility and balance disturbance, as a consequence. Impairment of mobility and balance is a common manifestation of illness in the frail individual and is therefore a sensitive marker of acute disease, putatively also in delirium. Clinical measurement of mobility and balance should be prioritized. Consequently, assessment tools, such as the de Morton Mobility Index and the Hierarchical Assessment of Balance and Mobility, are being explored, with the sensitivity of the latter illustrated in the acute hospital setting. Walking with speed and under dual/multi-task conditions better differentiates healthier and frail ambulant adults, providing a basis for screening older adults for pre-emptive interventions. Specific mobility and balance interventions reduce falls risk. However, patients with dementia walk too fast for their level of frailty, creating an ethical dimension to rehabilitation and risk. Overall, there is no need for reduced mobility to reinforce the frailty stereotype; both are potentially modifiable and amenable to intervention strategies.

Delirium is poorly recognised and inadequately treated in medical settings. This research aimed to determine the psychometric properties of a newly developed tool, SQeeC against another emergent instrument, SQiD, in the screening of delirium.The SQeeC was administered to 100 patients and SQiD administered to their informants in the general medical wards of a General Hospital. Data were compared with the reference standard geriatric consultant assessment of delirium.Compared with the reference standard, the SQeeC was found to have a sensitivity of 83% (95% CI 52-98%) and a specificity of 81% (95% CI 72-89%) with a negative predictive value of 97% (95% CI 90-100%) while the SQiD was found to have a sensitivity of 77% (95% CI 56-91%), a specificity of 51% (95% CI 37-64%) and a negative predictive value of 83% (95% CI 66-93%).The SQeeC and SQiD are simple and time efficient screening tools with encouraging psychometric properties.

Sleep disturbance is a clinically significant problem in nearly one half of patients with dementia and is a predictor of cognitive and functional decline. There are multiple causes of sleep disturbance in dementia and all represent diagnostic and management challenges. Impaired circadian rhythm is a disorder characterized by an increase in daytime sleep with reduced night-time sleep, a reversal of the sleep/wake cycle. Such disrupted circadian rhythm may occur early in Alzheimer's disease, worsen over time, and is associated with behavioural disturbance, including aggression. In addition to the timing of sleep, the structure of sleep may deteriorate, giving rise to poor sleep quality.

Frailty represents a state of heightened vulnerability. Mobility impairment contributes to the construct of frailty and channels adverse events. While mobility disorder is universal at a high burden of frailty, neither mobility nor balance dysfunction is sufficient to fully define frailty. Frailty represents proximity to complex system failure, with higher-order disturbance, such as mobility and balance disturbance, as a consequence. Impairment of mobility and balance is a common manifestation of illness in the frail individual and is therefore a sensitive marker of acute disease, putatively also in delirium. Clinical measurement of mobility and balance should be prioritized. Consequently, assessment tools, such as the de Morton Mobility Index and the Hierarchical Assessment of Balance and Mobility, are being explored, with the sensitivity of the latter illustrated in the acute hospital setting. Walking with speed and under dual/multi-task conditions better differentiates healthier and frail ambulant adults, providing a basis for screening older adults for pre-emptive interventions. Specific mobility and balance interventions reduce falls risk. However, patients with dementia walk too fast for their level of frailty, creating an ethical dimension to rehabilitation and risk. Overall, there is no need for reduced mobility to reinforce the frailty stereotype; both are potentially modifiable and amenable to intervention strategies.

Background The incidence of clinically apparent stroke in transcatheter aortic valve implantation (TAVI) exceeds that of any other procedure performed by interventional cardiologists and, in the index admission, occurs more than twice as frequently with TAVI than with surgical aortic valve replacement (SAVR). However, this represents only a small component of the vast burden of neurological injury that occurs during TAVI, with recent evidence suggesting that many strokes are clinically silent or only subtly apparent. Additionally, insult may manifest as slight neurocognitive dysfunction rather than overt neurological deficits. Characterisation of the incidence and underlying aetiology of these neurological events may lead to identification of currently unrecognised neuroprotective strategies. Methods The Silent and Apparent Neurological Injury in TAVI (SANITY) Study is a prospective, multicentre, observational study comparing the incidence of neurological injury after TAVI versus SAVR. It introduces an intensive, standardised, formal neurologic and neurocognitive disease assessment for all aortic valve recipients, regardless of intervention (SAVR, TAVI), valve-type (bioprosthetic, Edwards SAPIEN-XT) or access route (sternotomy, transfemoral, transapical or transaortic). Comprehensive monitoring of neurological insult will also be recorded to more fully define and compare the neurological burden of the procedures and identify targets for harm minimisation strategies. Discussion The SANITY study undertakes the most rigorous assessment of neurological injury reported in the literature to date. It attempts to accurately characterise the insult and sustained injury associated with both TAVI and SAVR in an attempt to advance understanding of this complication and associations thus allowing for improved patient selection and procedural modification.

Introduction: hip fracture is expensive in terms of mortality, hospital length of stay (LOS) and consequences for independence. Poor outcome reflects the vulnerability of patients who typically sustain this injury, but the impact of different comorbidities and impairments is complex to understand. We consider this in a prospective cohort study designed to examine how a patients’ frailty index (FI) predicts outcome. Methodology: consecutive patients with low trauma hip fracture were assessed, excluding only those unfit for surgery. Comprehensive Geriatric Assessment (CGA) findings were used to derive a FI for each patient, which was examined alongside other assessment and outcome data from our National Hip Fracture Database (NHFD) submission for these individuals. Results: we describe 178 patients; mean age 81 years, 73.5% female. The mean FI was 0.34 (SD = 0.16), and logistic regression identified abbreviated mental test score and FI as the strongest predictors of poor outcome. When patients were stratified by FI, 56 (31.5%) were in the low-frailty group (FI ≤0.25), 58 (32.5%) in intermediate (FI >0.25–0.4), and 64 (36%) in the high-FI group (FI >0.4). All the patients in the low-FI group returned to their original residence within a mean of 21.6 days. The mean LOS for the intermediate group was 36.3 days compared with 67.8 days in the high-FI group (P< 0.01) while 30-day mortality was 3.4% for the intermediate group compared with 17.2% for the high-FI group (P< 0.001). Conclusions: individual CGA findings proved disappointing as outcome predictors, while FI turned out to be a better predictor of mortality, 30-day residence and length of inpatient stay.

A new model of care for the management of patients with delirium was developed and evaluated.A four-bedded Close Observation Unit (COU) was introduced. The model comprised education for assistants in nursing (AINs), environmental adaptations and AIN-to-patient ratio of 1:4. Outcomes in all patients with delirium before and after introduction of the new model of care were compared.One hundred and five patients were admitted to COU, of whom 100 (95%) were diagnosed with delirium. In-hospital mortality improved after introduction of the unit (15% vs 5%; P = 0.002) without significant change in length of stay, discharge destination or falls frequency.A dedicated unit for delirium management within medicine achieved a reduction in mortality.

Background: Despite the impact and importance of end-of-life discussions, little is known about how physicians discuss cardiopulmonary resuscitation (CPR) with patients and their families. The necessary components for successful communication about CPR are poorly understood and an established framework to structure these conversations is lacking. Here, we were motivated to understand how physicians approach resuscitation planning with families when older patients have limited life expectancy and a high burden of illness. Method: Qualitative analysis was conducted of semi-structured interviews of 28 physicians of varying medical sub-specialties in a tertiary care hospital. Results: Most physicians explored the surrogates’ goals and values, but few provided explicit information about the patients’ overall health status or expected long-term health outcome related to CPR and underlying illnesses. Conclusion: There is considerable heterogeneity in physicians’ approaches to CPR discussions. The principle of autonomy is dominant with less emphasis on providing adequate information for effective decision-making.

Archetypal symptoms and signs are commonly absent in frail older people who are acutely unwell. This challenges both recognition of illness and monitoring of disease progression in people at high risk of prolonged hospital stays, institutionalization and death.To determine whether bedside assessment of balance and mobility could track acute changes in the health status of older people admitted to hospital.Prospective cohort study.Four hundred nine patients, with a mean age of 81.8 years, admitted to general medical and rehabilitation wards at a tertiary care teaching hospital in Halifax, Nova Scotia. No patient refused assessment, and the only exclusion criterion was age.The Hierarchical Assessment of Balance and Mobility (HABAM) was completed daily during the first 2 weeks of admission. For each patient, frailty status was measured on admission by a Frailty Index based on a Comprehensive Geriatric Assessment (FI-CGA).Death and discharge destination.Poor performance in balance, transfers and mobility was associated with adverse outcomes. Forty-eight percent of patients with the lowest scores in all three domains died, compared with none with the highest scores. The relative risk of death for people who deteriorated during the first 48 h of admission was 17.1 (95% confidence interval: 4.9-60.3). Changes in HABAM scores were related to the discharge destination: patients discharged home showed the greatest rate of improvement, whereas those discharged to institutions stabilised at a lower level of performance. Fitter patients tended to have better performance on admission and faster recovery.Daily bedside observation of mobility and balance allows assessment of acute changes in the health of older people. Frailty slows recovery of mobility and balance, and reduces recovery potential. By identifying patients most vulnerable to adverse outcomes, the HABAM and FI-CGA may facilitate risk stratification in older people admitted to hospital.

Delirium is a disorder affecting consciousness, which gives rise to core clinical features and associated symptoms. Older patients are particularly prone, owing to higher rates of pre-existing cognitive impairment, frailty, co-morbidity and polypharmacy.The aim of this study was to investigate the hypotheses that delirium affects the most vulnerable older adults and is associated with long-term adverse health outcome.This prospective cohort study evaluated 278 medical patients agedor = 75 years admitted acutely to a district general hospital in South Wales. Patients were screened for delirium at presentation and on alternate days throughout their hospital stay. Assessments also included illness severity, preadmission cognition, co-morbidity and functional status. Patients were followed for 5 years to determine rates of institutionalisation and mortality. Number of days in hospital in the 4 years prior to and 5 years after index admission were recorded.Delirium was detected in 103 patients and excluded in 175. Median time to death was 162 days (interquartile range 21-556) for those with delirium compared with 1,444 days (25% mortality 435 days, 75% mortality5 years) for those without (P0.001). After adjusting for multiple confounders, delirium was associated with an increased risk of death (hazard ratio range 2.0-3.5; Por = 0.002). Institutionalisation was higher in the first year following delirium (P = 0.03). While those with delirium tended to be older with more preadmission cognitive impairment, greater functional dependency and more co-morbidity, they did not spend more days in hospital in the 4 years prior to index admission.Delirium is associated with high rates of institutionalisation and an increased risk of death up to 5 years after index event. Prior to delirium, individuals seem to compensate for their vulnerability. The impact of delirium itself, directly or indirectly, may convert vulnerability into adverse outcome.

Background: Populations worldwide are aging and the overall prevalence of dementia at death is now 30%. Since the contemporary social impact of a disease is indicated by the frequency of its newspaper coverage and since obituary notices illuminate conceptions of death, we hypothesized that obituary notices placed by families would reflect societal attitudes to aging and dementia.Methods: We undertook critical discourse analysis of obituaries in representative national and local newspapers in Canada and the U.K.Results: In the 799 obituaries studied, chronological age, suggested donations in memory of the deceased, and donations to dementia charities were each included in significantly more obituaries in Canadian newspapers than in U.K. ones. Military service was explicit for significantly more men aged ≥ 80 years in Canada compared to the U.K. (41% versus 4%; p < 0.05). Of the donations to medical charities, nearly half (n = 117) were to cancer charities and one-fifth (54) to heart and stroke foundations. In the U.K., obituaries for those aged ≥ 70 years were more likely to recommend donations to children's charities (n = 12) or the Royal National Lifeboat Institution (8) than dementia charities (7).Conclusions: Donations to dementia charities were significantly more common in obituaries in Canada than in the U.K. In both countries, donations to medical charities did not reflect disease prevalence or impact to the individual. Societal attitudes in the U.K. may be impacted by the fragmentation of aging research and antipathy to geriatric medicine in the national medical press.

Background Delirium is a commonly occurring complex neuropsychiatric disorder. Evidence for its treatment based on randomizedcontrolledtrials (RCTs) is poor. Aims To determine the efficacy and acceptability of quetiapine in the treatment of delirium. Method A double-blind, RCT was conducted. A total of 42 patients were randomized to quetiapine or aplacebo group. The primary outcome measure was the Delirium Rating Scale Revised 98. Other scales used were the Brief Psychiatric Rating Scale, Mini-Mental State Examination and Clinical Global Improvement. In order to account for missing data, a nonlinear mixed-effects model was used to estimate the difference between the two groups. Results The quetiapine group improved more rapidly than the placebo group. Specifically, the quetiapine group recovered 82.7% faster (S.E. 37.1%, P=.026) than the placebo group in terms of DRS-R-98 severity score. In terms of the DRS-R-98 noncognitive subscale, the quetiapine group improved 57.7% faster (S.E. 29.2%, P=.048) than the placebo group. Conclusions Quetiapine has the potential to more quickly reduce the severity of noncognitive aspects of delirium. This study was underpowered for treatment comparisons at specific points in time but nonetheless detected significant differences when analyzing the whole study period. While it is not possible to draw definitive conclusions, further larger studies exploring the use of quetiapine in other delirium populations seem justified. Larger increments in the dose of quetiapine may yield even stronger results.

Delirium is a common problem in post-acute and long-term care. We present an updated review of delirium in those settings. Special considerations are the border between delirium and dementia, and in knowing when what presents as delirium might be the type of preterminal cognitive decline that manifests among people who are dying. A work-up that focuses on the common causes of delirium (which, in essence, are the common illnesses that befall frail older adults) is likely to have a high yield. We note that preventing delirium requires a multicomponent approach, the details of much of which is known, but nevertheless have proved to be challenging to bring about in routine care.