Seki A. Balogun

Delirium, a Symptom of UTI in the Elderly: Fact or Fable? A Systematic Review*

Background In geriatrics, delirium is widely viewed as a consequence of and, therefore, a reason to initiate workup for urinary tract infection (UTI). There is a possibility that this association is overestimated. To determine the evidence behind this clinical practice, we undertook a systematic review of the literature linking delirium with UTI. Methods A MEDLINE search was conducted from 1966 through 2012 using the MESH terms “urinary tract infection” and “delirium”, limited to humans, age 65 and older. The search identified 111 studies. Of these, five met our inclusion criteria of being primary studies that addressed the association of UTI and delirium. The studies were four cross-sectional observational studies and one case series. No randomized control trials were identified. All studies were published between 1988 and 2011. Four collected data retrospectively and one prospectively, with study sizes ranging from 14 to 1,285. The methodological strength of the studies was evaluated using six standards adapted from a previous systematic review. Results Only two of the five studies adequately matched or statistically adjusted for differences in comparison groups. None of the studies evaluated subjects with equal intensity for the presence of delirium and UTI, nor did they have objective criteria for either diagnosis. In subjects with delirium, UTI rates ranged from 25.9% to 32% compared to 13% in those without delirium. In subjects with UTI, delirium rates ranged from 30% to 35%, compared to 7.7% to 8% in those without UTI. Conclusions Few studies have examined the association between UTI and delirium. Though the studies examined conclude that there is an association between UTI and delirium, all of them had significant methodological flaws that likely led to biased results. Therefore, it is difficult to ascertain the degree to which urinary tract infections cause delirium. More research is needed to better define the role of UTI in delirium etiology.

Screening for Depression in Elderly Hemodialysis Patients

Background: Depression is common and associated with increased morbidity and mortality in elderly (≧65 years) hemodialysis patients. Beck’s Depression Inventory (BDI) and the Geriatric Depression Scale (GDS) have been used in different cohorts to screen for depression. Objectives: We aimed to evaluate the 15-item GDS (GDS-15) as such a tool in elderly hemodialysis patients and compare it with BDI, a previously validated tool in younger hemodialysis patients. Design: Cross-sectional study. Setting: Four out-patient hemodialysis units; 1 based in a university hospital and 3 based in the community. Participants: Hemodialysis patients aged 65 years and older. Intervention: Both tools were administered to all participants, and a geriatric psychiatrist blinded to the results evaluated them for depression by the gold standard psychiatric interview. Measurements: The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for both tools were assessed against the psychiatric interview (n = 62). Results: Patients who were depressed according to the psychiatric interview had significantly higher GDS-15 and BDI scores compared to those not depressed (p < 0.01 both). ROC curves showed high predictive accuracy of the GDS-15 and BDI (area under the curve: 0.808 and 0.729) versus the psychiatric interview. The GDS-15 cutoff with the best diagnostic accuracy was 5 with a sensitivity of 63%, specificity of 82%, PPV of 60% and NPV of 83%. The BDI cutoff with the best diagnostic accuracy was 10 with a sensitivity of 68%, specificity of 77%, PPV of 57% and NPV of 85%. Conclusion: These results provide evidence that the GDS-15 shows validity in comparison to a gold standard and can be used to screen for depression in the elderly hemodialysis population.

Quality of Life, Perceptions, and Health Satisfaction of Older Adults with End‐Stage Renal Disease: A Systematic Review

To explore the quality of life (QOL), perceptions, and health satisfaction of older adults with end‐stage renal disease (ESRD) undergoing renal replacement therapy (RRT).

Innovative interprofessional geriatric education for medical and nursing students: focus on transitions in care.

BACKGROUND Interprofessional education (IPE) is crucial in fostering effective collaboration and optimal team-based patient care, all of which improve patient care and outcomes. Appropriate interprofessional communication is especially important in geriatrics where patients are vulnerable to adverse effects across the care continuum. Transitions in geriatric care are complex, involving several disciplines and requiring careful coordination. As part of the University of Virginias initiative on IPE, we developed and implemented an interprofessional geriatric education workshop for nursing and medical students with a focus on transitions in care. METHODS A total of 254 students (144 medical students, 107 nursing students and 3 unknown) participated in a 90-min interactive, case-based workshop. Nursing and medical faculty facilitated the monthly workshops with small groups of medical and nursing students over 1 year. Self-perceived competencies in IPE skills and attitudes toward interprofessional teamwork were measured through post-workshop surveys. Data were analyzed using descriptive and nonparametric statistics, excluding the three unknown students. RESULTS Over 90% of students were better able to describe the necessary interprofessional communication needed to develop a patient-centered care plan in transitioning patients between clinical sites. Four out of five students reported an enhanced appreciation of interprofessional teamwork. They were also able to identify legal, financial and social implications in transitions of care (75%). Nursing students consistently rated the workshop more highly than medical students across most domains (P < 0.05). CONCLUSIONS Students improved and demonstrated their knowledge of interprofessional communication and teamwork skills required in transitions of geriatric care. Introducing these concepts in medical and nursing training may help in fostering effective interprofessional communication and collaboration.

The 15-item geriatric depression scale as a predictor of mortality in older adults undergoing hemodialysis.

come. A previous study comparing patients admitted from long-term care and the community concluded that most long-term care residents did not regain prefracture function, but nursing home residents in this study were older and had more comorbidities including dementia that were likely to affect their rehabilitation potential. All patients in the current study participated in a coordinated multidisciplinary rehabilitation program with the specific aim of regaining sufficient function to return to their prefracture living arrangements. Despite this, a large proportion of individuals did not regain premorbid functional status, and not all returned to their premorbid residence; 38% were discharged to a long-term care facility, a figure that compares with other studies. These higher levels of care are costly and contribute to the hidden health economic burden of hip fracture. Furthermore, the reduction in social independence and function in these patients discharged to the community can significantly affect their quality of life. Although the current study had short follow-up, function at hospital discharge is a strong predictor of functional status at 1 year. The rising incidence of hip fractures reinforces the importance of preventing falls and fractures in older people. In 2008, the World Health Organization introduced the FRAX tool, which can be used to better identify people at high risk of fracture, and there is currently good evidence to support the use of many antiresorptive and anabolic drugs for fracture risk reduction. FRAX incorporates several known risk factors for fracture, along with bone mineral density T-score, if available, and calculates fracture probabilities from which treatment thresholds can be determined in individual countries. To encourage primary prevention of fracture at a national level, the use of FRAX should be encouraged among health professionals. To meet the challenges of increasing numbers of hip fracture in the future, strategies for management should encompass guidelines on prevention. Ongoing close liaison with orthopedic colleagues should continue to enhance the quality of care and recovery of older adults with hip fracture.

Reply to Comment on: Quality of Life, Perceptions, and Health Satisfaction of Older Adults with End-Stage Renal Disease

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