Gideon A. Caplan

A Randomized, Controlled Trial of Comprehensive Geriatric Assessment and Multidisciplinary Intervention After Discharge of Elderly from the Emergency Department—The DEED II Study

Objectives: To study the effects of comprehensive geriatric assessment (CGA) and multidisciplinary intervention on elderly patients sent home from the emergency department (ED).

Balance, reaction time, and muscle strength in exercising and nonexercising older women : a pilot study

Twenty-one women, aged 57 to 75 years, who had been taking part in exercise programs for periods of 12 months or more underwent tests of muscle strength, reaction time, proprioception, and body sway. The performance of these women in the tests was compared with 21 women of the same age who were not taking part in any organized physical activity and were not exercising more than 30 minutes a day. The women who had been taking part in the exercise program performed significantly better in the tests of quadriceps strength, reaction time, and sway on a compliant surface than the nonexercising women. The exercisers also had lower body mass index scores. These pilot results suggest that exercise may play a role in improving a number of sensori-motor systems that contribute to stability, and that exercise of this nature may help prevent falls in older women.

International Survey of Nursing Home Research Priorities

This article reports the findings of a policy survey designed to establish research priorities to inform future research strategy and advance nursing home practice. The survey was administered in 2 rounds during 2013, and involved a combination of open questions and ranking exercises to move toward consensus on the research priorities. A key finding was the prioritization of research to underpin the care of people with cognitive impairment/dementia and of the management of the behavioral and psychological symptoms of dementia within the nursing home. Other important areas were end-of-life care, nutrition, polypharmacy, and developing new approaches to putting evidence-based practices into routine practice in nursing homes. It explores possible innovative educational approaches, reasons why best practices are difficult to implement, and challenges faced in developing high-quality nursing home research.

Efficacy of Oral Risperidone, Haloperidol, or Placebo for Symptoms of Delirium Among Patients in Palliative Care: A Randomized Clinical Trial.

Importance Antipsychotics are widely used for distressing symptoms of delirium, but efficacy has not been established in placebo-controlled trials in palliative care. Objective To determine efficacy of risperidone or haloperidol relative to placebo in relieving target symptoms of delirium associated with distress among patients receiving palliative care. Design, Setting, and Participants A double-blind, parallel-arm, dose-titrated randomized clinical trial was conducted at 11 Australian inpatient hospice or hospital palliative care services between August 13, 2008, and April 2, 2014, among participants with life-limiting illness, delirium, and a delirium symptoms score (sum of Nursing Delirium Screening Scale behavioral, communication, and perceptual items) of 1 or more. Interventions Age-adjusted titrated doses of oral risperidone, haloperidol, or placebo solution were administered every 12 hours for 72 hours, based on symptoms of delirium. Patients also received supportive care, individualized treatment of delirium precipitants, and subcutaneous midazolam hydrochloride as required for severe distress or safety. Main Outcome and Measures Improvement in mean group difference of delirium symptom score (severity range, 0-6) between baseline and day 3. Five a priori secondary outcomes: delirium severity, midazolam use, extrapyramidal effects, sedation, and survival. Results Two hundred forty-seven participants (mean [SD] age, 74.9 [9.8] years; 85 women [34.4%]; 218 with cancer [88.3%]) were included in intention-to-treat analysis (82 receiving risperidone, 81 receiving haloperidol, and 84 receiving placebo). In the primary intention-to-treat analysis, participants in the risperidone arm had delirium symptom scores that were significantly higher than those among participants in the placebo arm (on average 0.48 Units higher; 95% CI, 0.09-0.86; P = .02) at study end. Similarly, for those in the haloperidol arm, delirium symptom scores were on average 0.24 Units higher (95% CI, 0.06-0.42; P = .009) than in the placebo arm. Compared with placebo, patients in both active arms had more extrapyramidal effects (risperidone, 0.73; 95% CI, 0.09-1.37; P = .03; and haloperidol, 0.79; 95% CI, 0.17-1.41; P = .01). Participants in the placebo group had better overall survival than those receiving haloperidol (hazard ratio, 1.73; 95% CI, 1.20-2.50; P = .003), but this was not significant for placebo vs risperidone (hazard ratio, 1.29; 95% CI, 0.91-1.84; P = .14). Conclusions and Relevance In patients receiving palliative care, individualized management of delirium precipitants and supportive strategies result in lower scores and shorter duration of target distressing delirium symptoms than when risperidone or haloperidol are added. Trial Registration anzctr.org.au Identifier: ACTRN12607000562471.

Sensori-motor Function in Older Persons with Diabetes

Twenty‐five persons with diabetes (aged 55–83 years) who were living independently in the community, and 40 age‐ and sex‐matched non‐diabetic controls were assessed for tactile sensitivity, vibration sense, proprioception, quadriceps strength and body sway. In both men and women, those with diabetes performed significantly worse in tests of body sway on firm and compliant surfaces compared with the control subjects after controlling for weight and body mass index. The female diabetic subjects also performed significantly worse in tests of peripheral sensation and strength compared with controls. Age‐related declines in sensori‐motor function were greater in the diabetic group (r = 0.55–0.75) than in the controls (r < 0.44), while within the diabetic group, duration of diabetes and vibration sense were significantly correlated with sway on a compliant (foam rubber) surface with the eyes open (partial r = 0.52, p < 0.01 and r = 0.55, p < 0.01, respectively). The study findings provide evidence that older people with diabetes have problems with stability and related sensori‐motor factors which may place them at increased risk of falls.

A randomised controlled trial of the costs of hospital as compared with hospital in the home for acute medical patients

OBJECTIVE: To test the cost effectiveness of Hospital in the Home compared to hospital admission for acute medical conditions.

The Diagnosis of Delirium Superimposed on Dementia: An Emerging Challenge

Delirium occurring in patients with dementia is referred to as delirium superimposed on dementia (DSD). People who are older with dementia and who are institutionalized are at increased risk of developing delirium when hospitalized. In addition, their prior cognitive impairment makes detecting their delirium a challenge. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition and the International Statistical Classification of Diseases and Related Health Problems, 10th Revision are considered the standard reference for the diagnosis of delirium and include criteria of impairments in cognitive processes such as attention, additional cognitive disturbances, or altered level of arousal. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition and the International Statistical Classification of Diseases and Related Health Problems, 10th Revision does not provide guidance regarding specific tests for assessment of the cognitive process impaired in delirium. Importantly, the assessment or inclusion of preexisting cognitive impairment is also not addressed by these standards. The challenge of DSD gets more complex as types of dementia, particularly dementia with Lewy bodies, which has features of both delirium and dementia, are considered. The objective of this article is to critically review key elements for the diagnosis of DSD, including the challenge of neuropsychological assessment in patients with dementia and the influence of particular tests used to diagnose DSD. To address the challenges of DSD diagnosis, we present a framework for guiding the focus of future research efforts to develop a reliable reference standard to diagnose DSD. A key feature of a reliable reference standard will improve the ability to clinically diagnose DSD in facility-based patients and research studies.

Home sweet home? Community care for older people in Australia.

Community care provision for older Australians is growing in places and options, based on older peoples preference to stay in their own homes, coupled with its cost efficiency compared to long-term residential care. Australias aging population, cultural diversity, and dispersed population in rural and remote areas presents significant challenges in meeting these care needs. The objective of this review is to provide a critical overview of community care services in Australia, from its origin in the 1940s through to the current array of programs that deliver care. Barriers to access for these programs, growth in funding and expenditure, evidence of client satisfaction and the problems of workforce provision are presented. It is not clear how the growing future demands for care programs, resulting from greater client expectation, increasingly complex care needs and a diminishing workforce of paid and unpaid carers, will be met. However, the economic burden is anticipated to be manageable. Despite seemingly well-structured programs, the current multiplicity and rigidity of services means care provided is sometimes unsatisfactory at the point of delivery. It remains to be seen therefore if services can be expanded, modified and developed to address current deficiencies and meet future demands. The reality of timely and equitable care for all older Australians living in the community is elusive at present. The ongoing rationing of residential care beds coupled with peoples desires to stay in their own homes means community care is here to stay. The future inevitably presents huge challenges to those planning, implementing and providing care in this setting.

Cerebrospinal Fluid in Long-Lasting Delirium Compared With Alzheimer’s Dementia

BACKGROUND Delirium is a common syndrome affecting older people in hospital, whose pathophysiology is poorly understood, but sequelae of increased cognitive and functional impairment suggest neuronal loss. METHODS Cohort study comparing cerebrospinal fluid, blood, and clinical markers of delirium and neuronal cell death in 20 older hospitalized patients with delirium and 20 outpatients with Alzheimers dementia. RESULTS Compared with participants with dementia, patients with delirium demonstrated higher CSF lactate (1.87 vs 1.48 mmol/L, p < .001) and protein levels (0.62 vs 0.44 g/L, p = .036) and lower levels of neuron-specific enolase (4.84 vs 8.98 ng/mL, p < .001) but no difference in S100B. The changes correlated with clinical indices and outcomes. CONCLUSION Older patients with delirium experience significant metabolic disturbance in the brain, which requires further investigation.

Attitudes to osteoporosis and hormone replacement therapy among elderly women.

Abstract: This study compares the attitudes toward osteoporosis and its treatment between a group of elderly women admitted to hospital for therapy of an osteoporotic fracture and a control group admitted for joint replacement surgery. We surveyed 97 women (64 with a fracture, and 33 controls) and found that the two groups of patients demonstrated a similar risk factor profile for osteoporosis and poor knowledge of osteoporosis and its available treatments, including hormone replacement therapy (HRT). By selecting a control group of women with no recent fracture, we hoped to highlight the effect of sustaining a recent fracture on attitudes to treatment. Initially only 10% (8 in the fracture group and 2 in the control group) were interested in treatment for osteoporosis, but those women who had been admitted with a fracture were significantly more receptive to education about osteoporosis and to the offer of further investigation and treatment of osteoporosis (38 versus 10, p= 0.007). We conclude that it is worthwhile offering education, screening and treatment to elderly patients who present with a fracture.