Joseph H. Flaherty

China: The Aging Giant

This article examines the changing demographics of China, with particular attention paid to the effect of the one‐child policy in relation to long‐term care of older people. It also examines the current state of health care for older people. Long‐term stays characterize hospital care. Most geriatric syndromes are less common in hospitalized older people (e.g., delirium, falls), but some (e.g., polypharmacy) are more common. A high volume of patients and brief targeted visits characterize outpatient care. Nursing homes exist in China, but relatively fewer than in the most developed countries.

A Model for Managing Delirious Older Inpatients

Although multiple models of care exist to prevent the development of delirium in hospitalized patients, models for the management of patients for whom delirium is unpreventable or who already have delirium on admission to the hospital are needed.

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.

Antipsychotics in the treatment of delirium in older hospitalized adults: a systematic review.

To examine evidence of the efficacy of antipsychotics in the treatment of delirium in older hospitalized adults.

The development of outpatient clinical glidepaths

For clinicians who are struggling with the complexities of medical decision‐making, practice guidelines and evidence‐based medicine (EBM) have become increasingly popular and have potential to positively influence the practice of medicine. Nevertheless, they have their limitations. Guidelines are often rigid, based solely on age, and usually do not take into account a patients comorbidities, life expectancy, and nonmedical preferences. EBM studies may not always include particular patient populations commonly seen by the geriatric clinician (e.g., studies on lipid‐lowering agents or antihypertensive drug usually exclude the very old or patients who are frail, demented, or at the end of life). These limitations have made it difficult for geriatric clinicians to use these guidelines because of the need to individualize evaluation and treatment approaches and take into account the varied preferences of their older patients. The purpose of this paper is to present an alternative model of care for geriatric clinicians called The Clinical Glidepaths. The Clinical Glidepaths are outpatient tools intended to assist geriatric clinicians in their decision‐making process. They are based on the following principles. (1) Clinicians need guidance concerning many different types of patients, not rigid guidelines based solely on age. (2) EBM should be used but has some limitations of which to be aware. (3) Clinical experience, which emphasizes individual outcomes instead of populations, is an important component of medical decisions. (4) There needs to be room for patient preferences in medical decision‐making. (5) An approach to patients based on probable life expectancy and function, instead of age, will be more applicable and useful. (6) Making a useful tool will focus on common problems seen in every day geriatric practices.

A pilot study of the SARC-F scale on screening sarcopenia and physical disability in the Chinese older people.

IntroductionThe SARC-F scale is a newly developed tool to diagnose sarcopenia and obviate the need for measurement of muscle mass. SARC-F ≥ 4 is defined as sarcopenia. The questions of SARC-F cover physical functions targeting sarcopenia or initial presentation for sarcopenia. The aim of the study is to explore the application of SARC-F in the Chinese people.MethodsTwo hundred thirty Chinese people over 65 years old were assessed by the SARC-F scale, PSMS, Lawton IADL and the shortened version of the falls efficacy scale-international (the short FES-I). Hospitalization was investigated. Physical performance and strength were measured. The association of SARC-F with other scales or tests was analyzed.ResultsPoor physical performance and grip strength were associated with SARC-F ≥ 4 independently (P<0.005). The value for agreement of SARC-F ≥ 4 and cutoff points of tests were 0.391 to 0.635. The short FES-I were correlated to SARC-F scores (Spearman’s coefficient 0.692). Poor PSMS and Lawton IADL scores were associated with SARC-F ≥ 4(P=0.000) and SARC-F ≥ 4 was associated with hospitalization in the past 2 years (P=0.000).ConclusionThe SARC-F scale can identify old Chinese people with impaired physical function who may suffered from sarcopenia. SARC-F judgment reflects fear of falling, indicates the hospitalization events and is associated with ability of daily life. Thus, SARC-F may be a simple and useful tool for screening individuals with impaired physical function. Further studies on SARC-F in Chinese people would be worthy.

The Effect of Aging on Bone Mineral Metabolism and Bone Mass in Native American Women

OBJECTIVE: To examine the effect of age on mineral metabolism and bone mineral density (BMD) of the hip and spine in Native American women.

Decreasing Hospitalization Rates for Older Home Care Patients with Symptoms of Depression

OBJECTIVE: To target medically ill older home care patients with symptoms of depression in order to reduce their rate of hospitalization.

An ACE Unit With a Delirium Room May Improve Function and Equalize Length of Stay Among Older Delirious Medical Inpatients

BACKGROUND Patients with delirium, compared with those without, are at increased risk for loss of function, longer hospital stays, and increased mortality. We studied the effect that an Acute Care of the Elderly Unit, which includes a delirium room, has on patients with delirium. METHODS Retrospective observational study. Charts of 148 patients (≥65 years) admitted to an Acute Care of the Elderly Unit with a delirium room during a 4-month period were reviewed. Delirium on admission (prevalence) was based on physician-performed Confusion Assessment Method; delirium during hospital stay (incidence) was based on nurse-performed Confusion Assessment Method. Patients with delirium were compared with those without delirium regarding change in function between admission and discharge (activities of daily living), hospital length of stay, and mortality. RESULTS The prevalence of delirium was 16.2% (24/148), and the incidence was 16.1% (20/124). There were no significant differences between delirious and non-delirious patients in demographics or comorbidity scores. A significant interaction effect (p < .001) indicated improved activities of daily living (mean ± SD; scale 0-12) between admission and discharge among delirious patients (4.1 ± 4.6 and 6.1 ± 3.9) compared with non-delirious patients (7.4 ± 4.7 and 6.9 ± 4.5). There were no differences between delirious and non-delirious patients with reference to mean length of stay (6.4 ± 3.1 vs 5.9 ± 3.6 days, respectively; p = .461) and mortality (2 [4.5%] versus 2 [1.9%], respectively; p = .582). CONCLUSIONS Although this study sample was small, the results suggest that an Acute Care of the Elderly Unit with a delirium room may improve function among delirious patients and may equalize other outcomes compared with non-delirious patients.

Delirium in the Nursing Home

New-onset or subsyndromal delirium is one of the most disruptive conditions in nursing home life. As shown in this issue of the Journal, delirium occurs in nearly 1 in 5 nursing home residents who experience an acute illness, and delirium is a major risk factor for a noticeable decline in cognition following the acute episode.1 In 6 Dutch nursing homes, the prevalence of delirium was 8.9%, with an incidence of 20.7 per 100 person-years.2 A Canadian study in long term care residents found a prevalence of 3.4% in persons with a Mini Mental Status Examination (MMSE) of greater than 10 and 33.3% in those with a lower MMSE.3 A large study of 35,721 long term stay residents in the United States using the Minimum Data Assessment 2.0 found that 1.4% had delirium and 30.4% had subsyndromal delirium.4 Other studies have found a higher prevalence of delirium on admission to postacute care ranging from 5.5% to 51.0%.5e8 Many residents remain in a state of subsyndromal delirium over a prolonged period of time. Delirium is often unrecognized.9 One of the most commonly used and best validated screening tools in the United States for delirium is the Confusion Assessment Methodology (CAM).10 The key components of diagnosis are acute onset, fluctuation throughout the day, inattention, disorganized thinking, and abnormal level of consciousness. The new Minimum Data Set, Version 3.0, includes a modification of the CAM screen for delirium.11 Studies have suggested that nurses in nursing homes fail to identify almost half the cases of delirium,12 even though they can differentiate delirium from dementia and depression.13 When the CAM is used, there is a greater reliability of identifying delirium in the nursing home.14 Delirium has been recognized as a serious and underrecognized problem, leading to the suggestion that mental status should be considered the sixth vital sign.15 The Department of Veterans Affairs Delirium Working Group has developed a simple pictorial mental status vital sign to improve recognition of delirium.16 Based on this concept, a modified version of the Richmond Agitation and Sedation Scale (mRASS) was developed. If the mRASS assessments (which take <30 seconds on average to perform) were done serially (from shift to shift), a change indicated incident deliriumwith a sensitivity of 85% and specificity of 92%.17 In addition, all new-onset falls in the nursing home should be considered to be a delirium equivalent until proven otherwise.18e22