Background Since in hospitalized older patients delirium is associated with poor outcomes, we evaluated the effectiveness of a multicomponent strategy for the prevention of delirium. Methods We studied 852 patients 70 years of age or older who had been admitted to the general-medicine service at a teaching hospital. Patients from one intervention unit and two usual-care units were enrolled by means of a prospective matching strategy. The intervention consisted of standardized protocols for the management of six risk factors for delirium: cognitive impairment, sleep deprivation, immobility, visual impairment, hearing impairment, and dehydration. Delirium, the primary outcome, was assessed daily until discharge. Results Delirium developed in 9.9 percent of the intervention group, as compared with 15.0 percent of the usual-care group (matched odds ratio, 0.60; 95 percent confidence interval, 0.39 to 0.92). The total number of days with delirium (105 vs. 161, P=0.02) and the total number of episodes (62 vs. 9...

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A multicomponent intervention to prevent delirium in hospitalized older patients.

This study updates and expands explicit criteria defining potentially inappropriate medication use by the elderly. Additional goals were to address whether adverse outcomes were likely to be clinically severe and to incorporate clinical information on diagnoses when available. These criteria are meant to serve epidemiological studies, drug utilization review systems, health care providers, and educational efforts. Consensus from a panel of 6 nationally recognized experts on the appropriate use of medication in the elderly was sought. The expert panel agreed on the validity of 28 criteria describing the potentially inappropriate use of medication by general populations of the elderly as well as 35 criteria defining potentially inappropriate medication use in older persons known to have any of 15 common medical conditions. Updated, expanded, and more generally applicable criteria are now available to help identify inappropriate use of medications in elderly populations. These criteria define medications that should generally be avoided in the ambulatory elderly, doses or frequencies of administrations that should generally not be exceeded, and medications that should be avoided in older persons known to have any of several common conditions.

Explicit Criteria for Determining Potentially Inappropriate Medication Use by the Elderly: An Update

Epidemiology of Constipation in North America: A systematic review

PURPOSEComorbidity is a frequent and often therapeutically limiting problem in older cancer patients. However, to date, there is no standard measure of the comorbidity burden available for these patients. We tested the performance of two comorbidity scales and their relationship with functional status.PATIENTS AND METHODSThe Cumulative Illness Rating Scale-Geriatric (CIRS-G) was compared with the Charlson scale in 203 patients who received a comprehensive geriatric assessment (CGA) in our Senior Adult Oncology Program (SAOP). Study end points were variability, reliability, correlation with Eastern Cooperative Oncology Group (ECOG) performance status (PS), Activities of Daily Living (ADL), and Instrumental Activities of Daily Living (IADL). The relative weight of comorbidity versus tumor stage in the correlations with functional status was assessed.RESULTSMedian age was 75 years (range, 63 to 91). Sixty-four percent of patients scored 0 on the Charlson scale versus 6% on the CIRS-G. The correlation between...

Comorbidity and functional status are independent in older cancer patients.

BACKGROUND: While delirium has been increasingly recognized as a serious and potentially preventable condition, its long-term implications are not well understood. This study determined the total 1-year health care costs associated with delirium. METHODS: Hospitalized patients aged 70 years and older who participated in a previous controlled clinical trial of a delirium prevention intervention at an academic medical center between 1995 and 1998 were followed up for 1 year after discharge. Total inflation-adjusted health care costs, calculated as either reimbursed amounts or hospital charges converted to costs, were computed by means of data from Medicare administrative files, hospital billing records, and the Connecticut Long-term Care Registry. Regression models were used to determine costs associated with delirium after adjusting for patient sociodemographic and clinical characteristics. RESULTS: During the index hospitalization, 109 patients (13.0%) developed delirium while 732 did not. Patients with delirium had significantly higher unadjusted health care costs and survived fewer days. After adjusting for pertinent demographic and clinical characteristics, average costs per day survived among patients with delirium were more than 2(1/2) times the costs among patients without delirium. Total cost estimates attributable to delirium ranged from $16 303 to $64 421 per patient, implying that the national burden of delirium on the health care system ranges from $38 billion to $152 billion each year. CONCLUSIONS: The economic impact of delirium is substantial, rivaling the health care costs of falls and diabetes mellitus. These results highlight the need for increased efforts to mitigate this clinically significant and costly disorder. Language: en

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One-year health care costs associated with delirium in the elderly population.

Constipation in an elderly community : a study of prevalence and potential risk factors

Upper gastrointestinal tract symptoms are common in the elderly and, despite a paucity of data, nonsteroidal antiinflammatory drugs (NSAIDs) are believed to be important risk factors. We aimed to evaluate the association of NSAIDs with dyspepsia and heartburn in a population-based study. An age- and gender-stratified random sample of Olmsted County, Minnesota, Caucasian residents aged 65 years and older was mailed a valid self-report questionnaire; 74% responded (N=1375). Age- and gender-adjusted (to 1980 US Caucasian population) prevalence rates for NSAID use, dyspepsia (defined as pain located in the upper abdomen or nausea), and heartburn (defined as retrosternal burning pain) were calculated. Logistic regression analysis was used to estimate the association of dyspepsia and heartburn with potential risk factors adjusting for age and gender. The age- and gender-adjusted annual prevalences (per 100) of aspirin and nonaspirin NSAID use were 60.0 (95% CI 57.2,62.7) and 26.1 (95% CI 23.6,28.7), respectively. The annual prevalences of dyspepsia and heartburn were 15.0 (95% CI 12.9,17.0) and 12.9 (95% CI 10.9,14.8), respectively. Aspirin was associated with dyspepsia and/or heartburn (OR=1.6, 95% CI 1.2,2.2) as were nonaspirin NSAIDs (OR=1.8, 95% CI 1.3,2.6), but smoking and alcohol were not significant risk factors. Aspirin and nonaspirin NSAIDs are associated with almost a twofold risk of upper gastrointestinal tract symptoms in elderly community subjects.

Nonsteroidal antiinflammatory drugs and dyspepsia in the elderly

Objective To describe simple, practical measures of physical and psychosocial function to detect problems and enhance the care of elderly patients. Design We reviewed pertinent articles and current standard textbooks of geriatrics; the most useful findings are summarized, and tools that can be used for functional assessment of the geriatric population are presented. Results Care of elderly patients necessitates a comprehensive review of key areas of function. Using only clinical judgment, physicians may overlook important clinical deficits common in older patients. Because of their length and complexity, many of the standard geriatric assessment tools are impractical for use by primary-care physicians. Certain simplified or condensed versions—such as the Functional Reach Test and the "Get Up and Go" Test—are efficient substitutes. In this article, we describe methods for practical identification of functional impairments, assessment of cognition and mood, evaluation of hearing and vision, and detection of problems with continence, nutrition, and social needs. Instruments for assessment of caregiver burden are also outlined. Conclusion Use of the assessment tools presented herein can assist primary-care physicians in comprehensive evaluation of function in older patients.

Practical functional assessment of elderly persons: a primary-care approach.

Objective To describe the pharmacokinetic and pharmacodynamic changes that occur with aging and to discuss common problems noted with the use of medications often prescribed for elderly patients. Design We searched the medical literature, reviewed pertinent articles, and summarized drugrelated information applicable to geriatric patients. Results Use of medications is common in the elderly population; most elderly persons take two or more different medications each day. Aging is associated with anatomic and physiologic changes that can have an effect on how medications are handled. Such changes include alterations in various volumes of drug distribution and in drug absorption, metabolism, and clearance. Elderly patients may also have increased or decreased drug effects because of alteration in receptor response. These changes in pharmacokinetics and pharmacodynamics may result in a prolonged drug half-life, an increased potential for drug toxicity, and a greater likelihood for adverse drug reactions. Conclusion Medications for elderly patients should be prescribed only after the anatomic and physiologic changes of aging are understood and with increased surveillance for potential drug toxicity or adverse drug reactions.

Drug Prescribing for Elderly Patients

Objective To review the evaluation and management of delirium in elderly patients for primary-care providers. Design We summarize the clinical features, course, pathophysiologic aspects, predisposing factors, causes, and differential diagnosis of delirium and discuss approaches to affected patients and various management strategies. Results Delirium, an altered mental state, occurs more frequently in elderly than in younger patients. The pathophysiologic changes associated with aging and the higher occurrence of multiple medical problems and need for medications contribute to the higher frequency of delirium in elderly patients. Evaluation should begin with a consideration of the most common causes, such as a change in or addition to prescribed medications, a withdrawal from alcohol or other sedative-hypnotic drugs, an infection, or a sudden change in neurologic, cardiac, pulmonary, or metabolic state. Finally, management of delirium is threefold: (1) identifying and treating underlying causes, (2) nonpharmacologic interventions, and (3) pharmacologic therapies to manage symptoms of delirium. Conclusion Elderly patients frequently experience delirium. Delirious symptoms can produce devastating consequences if they are not recognized and appropriately treated.

Kevin C. Fleming

Papers

Constipation in an elderly community : a study of prevalence and potential risk factors

Nonsteroidal antiinflammatory drugs and dyspepsia in the elderly

Practical functional assessment of elderly persons: a primary-care approach.

Drug Prescribing for Elderly Patients

Delirium in elderly patients: evaluation and management.