[Detection, investigation, and management of delirium in hospitalized elderly].

Delirium is common in hospitalized older adults. The condition is frequently not recognized, or managed appropriately, and has a poor prognosis. This review finds that a proactive multicomponent interdisciplinary non-farmacological approach can reduce incidence. Delirium is managed by identification of the condition, accurate diagnosis and treatment of the causes, and all other correctable contributing factors, using nonpharmacologic approaches. In some cases, and if required for patient safety, low doses of high-potency antipsychotic agents can be used, in lowest possible dose and for the shortest possible time.

Perspective of geriatric patients on advance care planning in Denmark: a qualitative study.

OBJECTIVE: Most previous studies on advance care planning (ACP) have focused on patients with specific diseases and only a few on frail ageing individuals. We therefore decided to examine the perspective of geriatric patients on ACP. Our research questions include if, when, with whom and with which content geriatric patients wish to have ACP conversations. DESIGN: Participants were interviewed either in the hospital or in their own home. The interviewer followed a semistructured interview guide. Interviews were transcribed and analysed using the systemic text condensation method. SETTING: Geriatric department in a regional hospital in a rural area in Region Zealand, Denmark. PARTICIPANTS: We included 11 geriatric patients aged above 65 who had been referred for geriatric inpatient or outpatient assessment. Participants were clinically judged by experienced geriatricians to have sufficient physical and mental capacity to take part in an interview. RESULTS: This study's main finding is that geriatric patients have varying preferences and feelings towards ACP. Some expressed concerns about ACP, especially regarding personal fear to talk about end-of-life (EOL) decisions, and whether a busy healthcare system has the resources to conduct ACP. Proper timing of ACP seemed unrelated to specific age but related to perception of health situation. The health professional involved should be well trained and a person the participant could trust. Most participants wanted family members to participate. Concerning content, participants mentioned quality of life, fear of losing their spouse, earlier experience with death, and practical concerns regarding funeral and will. CONCLUSION: Among geriatric patients, feelings towards ACP are mixed. Even participants who were generally positive towards the concept uttered concerns about the circumstances when talking about EOL topics. Health professionals therefore should approach ACP discussions with caution. Further studies aiming to develop guidelines describing the proper way to introduce and perform ACP in this patient group are needed.

Frequency of missed or delayed diagnosis in dementia is associated with neighborhood socioeconomic status.

Introduction: Underdetection of dementia in areas with low socioeconomic status (SES) may interfere with findings concerning associations between SES and dementia. Methods: Using administrative registers we assessed the associations between age- and sex-adjusted dementia incidence and neighborhood socioeconomic status (nSES) in 94 Danish municipalities. Wealth was divided into income quartiles and other nSES variables were dichotomized into high versus low according to the median. Results: High population density (odds ratio [OR] 1.21, 95% confidence interval [CI] 1.18-1.24), higher proportion of inhabitants in higher income quartiles (P for trend < .0001), and high educational level (OR 1.19, 95% CI 1.15-1.22) were associated with higher incidence of dementia. High proportion of residents above 65 years was associated with lower age-adjusted dementia incidence (OR 0.86, 95% CI 0.84-0.89). Discussion: Low nSES municipalities have a lower age-adjusted incidence of dementia diagnosis. These findings corroborate prior concerns that a large number of dementia diagnoses may be missed in municipalities characterized by low SES.

Feasibility, quality and validity of narrative multisource feedback in postgraduate training: a mixed-method study.

OBJECTIVES: To examine a narrative multisource feedback (MSF) instrument concerning feasibility, quality of narrative comments, perceptions of users (face validity), consequential validity, discriminating capacity and number of assessors needed. DESIGN: Qualitative text analysis supplemented by quantitative descriptive analysis. SETTING: Internal Medicine Departments in Zealand, Denmark. PARTICIPANTS: 48 postgraduate trainees in internal medicine specialties, 1 clinical supervisor for each trainee and 376 feedback givers (respondents). INTERVENTION: This study examines the use of an electronic, purely narrative MSF instrument. After the MSF process, the trainee and the supervisor answered a postquestionnaire concerning their perception of the process. The authors coded the comments in the MSF reports for valence (positive or negative), specificity, relation to behaviour and whether the comment suggested a strategy for improvement. Four of the authors independently classified the MSF reports as either 'no reasons for concern' or 'possibly some concern', thereby examining discriminating capacity. Through iterative readings, the authors furthermore tried to identify how many respondents were needed in order to get a reliable impression of a trainee. RESULTS: Out of all comments coded for valence (n=1935), 89% were positive and 11% negative. Out of all coded comments (n=4684), 3.8% were suggesting ways to improve. 92% of trainees and supervisors preferred a narrative MSF to a numerical MSF, and 82% of the trainees discovered performance in need of development, but only 53% had made a specific plan for development. Kappa coefficients for inter-rater correlations between four authors were 0.7-1. There was a significant association (p<0.001) between the number of negative comments and the qualitative judgement by the four authors. It was not possible to define a specific number of respondents needed. CONCLUSIONS: A purely narrative MSF contributes with educational value and experienced supervisors can discriminate between trainees' performances based on the MSF reports.

[Episodic vestibular syndrome].

Dizziness and vertigo are frequent symptoms in the primary care facility and emergency departments. Episodic vestibular syndrome (EVS) is defined as episodic dizziness, vertigo or postural imbalance with remission between episodes. EVS can be divided into spontaneous (s-EVS) and triggered EVS (t-EVS). Causes of s-EVS are vestibular migraine, Menière's disease, transient ischaemic attack and vestibular paroxysmia. Causes of t-EVS are benign paroxysmal positionel vertigo, orthostatic hypotension and panick attacks. In this review, we recommend using vestibular syndromes in order to reduce the number of differential diagnoses.

[The chronically dizzy patient].

Many medical, neurologic and psychiatric conditions as well as drugs can give chronic dizziness, and a systematic diagnostic workup is essential. Chronic vestibular syndrome is a clinical syndrome of chronic vertigo, dizziness or unsteadiness lasting months to years. There is generally a persistent unilateral or bilateral vestibular loss. Treatment depends on the aetiology, but in general, treatment with vestibular rehabilitation is effective, which is summarised in this review. Betahistin or other anti-vertigo-drugs are not indicated in the treatment of chronic vertigo.

Predictive validity of PRISMA-7 as a screening instrument for frailty in a hospital setting.

OBJECTIVES: Frailty is a major clinical geriatric syndrome associated with serious adverse events including functional disability, falls, hospitalisation, increased morbidity and mortality. The aim of this study was to study the associations between frailty defined as Program of Research to Integrate Services for the Maintenance of Autonomy (PRISMA-7) score ≥3 and use of healthcare resources in hospital and in the municipality as well as association between frailty and mortality. DESIGN: Register-based retrospective study. SETTING: The target population consists of patients aged 75 years or above who, during hospital stay, were assessed by a physiotherapist, and at discharge from hospital were prescribed further physical training in the community. PARTICIPANTS: 973 individuals aged 75+ years were included. OUTCOME MEASURES: We examined associations between frailty and use of healthcare resources in hospital and in the municipality as well as the association between frailty and mortality. RESULTS: 973 individuals aged 75+ years were included. Of these, 63.9% had a PRISMA-7 score ≥3 and were thus defined as frail. Frail individuals were older compared with non-frail with mean ages of 84.6 and 80.4 years, respectively, p>0.001. Age and gender-adjusted mortality after 1 year was higher among the frail (OR 2.46, 95% CI 1.53 to 3.97). Use of healthcare services in the municipality as well as hospital admissions was significantly higher among frail individuals. CONCLUSIONS: Based on these findings we consider PRISMA-7 to be useful in an in-hospital setting as a screening tool to identify frail elderly patients who may profit from further geriatric assessment during hospital stay. TRIAL REGISTRATION NUMBER: ID REG-070-2017.

Effect of single follow-up home visit on readmission in a group of frail elderly patients - a Danish randomized clinical trial.

BACKGROUND: Unplanned hospital admissions are costly and prevention of these has been a focus for research for decades. With this study we aimed to determine whether discharge planning including a single follow-up home visit reduces readmission rate. The intervention is not representing a new method but contributes to the evidence concerning intensity of the intervention in this patient group. METHODS: This study was a centrally randomized single-center controlled trial comparing intervention to usual care with investigator-blinded outcome assessment. Patients above the age of 65 were discharged from a single Danish hospital during 2013-2014 serving a rural and low socioeconomic area. For intervention patients study and department nurses reviewed discharge planning the day before discharge. On the day of discharge, study nurses accompanied the patient to their home, where they met with the municipal nurse. Together with the patient they reviewed cognitive skills, medicine, nutrition, mobility, functional status, and future appointments in the health care sector and intervened if appropriate. Readmission at any hospital in Denmark within 8, 30, and 180 days after discharge is reported. Secondary outcomes were time to first readmission, number of readmissions, length of stay, and readmission with Ambulatory Care Sensitive Conditions, visits to general practitioners, municipal services, and mortality. RESULTS: One thousand forty-nine patients aged > 65 years discharged from medical, geriatric, emergency, surgical or orthopedic departments met inclusion criteria characteristic of frailty, e.g. low functional status, need of more personal help and multiple medications. Among 945 eligible patients, 544 were randomized. Seven patients died before discharge. 56% in the intervention group and 54% in the control group were readmitted (p = 0.71) and 23% from the intervention group and 22% from the control group died within 180 days. There were no significant differences between intervention and control groups concerning other secondary outcomes. CONCLUSIONS: There was no effect of a single follow-up home visit on readmission in a group of frail elderly patients discharged from hospital. TRIAL REGISTRATION: https://clinicaltrials.gov (identifier NCT02318680), retrospectively registered December 11, 2014.

Associations between the SHARE frailty phenotype and common frailty characteristics: evidence from a large Danish population study.

OBJECTIVES: Frailty is a major clinical geriatric syndrome associated with serious adverse events including functional disability, falls, hospitalisation, increased morbidity and mortality. The aim of this study was to study associations between a frailty phenotype and frailty characteristics well known from the literature. DESIGN: Registry-based cross-sectional study. SETTING: The target population consists of inhabitants above the age of 50 living in the Danish municipalities of Lolland and Guldborgsund. Excluded are incapacitated people, inhabitants unable to understand Danish or English and inhabitants without a permanent residence. PARTICIPANTS: 7327 individuals aged 50+ years were included. OUTCOME MEASURES: We examined associations between the frailty measurement and factors known to be associated with frailty: sex, age, income insufficiency, education, comorbidity, self-assessed health, morbidity and mortality. RESULTS: 7327 individuals aged 50+ years were included. Of these, 6.5% had ≥3 frailty components (frail), 46.7% had 1-2 components (prefrail) and 46.9% had none (non-frail). Those who were frail were older and more likely female than those who were non-frail or prefrail. There was a stepwise decrease in educational level, and in self-assessed health with increasing frailty status, and a stepwise increase in difficulty in making ends meet, number of hospital contacts and mortality with increasing frailty status, p<0.0001 for each comparison. Compared with individuals who were non-frail, mortality was higher among those who were prefrail (HR: 2.90; 95% CI: 1.30 to 6.43) or frail (HR: 8.21; 95% CI: 3.37 to 20.0). CONCLUSIONS: Based on these findings, we consider the Lolland-Falster Health Study frailty assessment a valid instrument demonstrating the same characteristics as other validated frailty measures concerning associations with sex, age, income insufficiency, education, comorbidity, self-assessed health, morbidity and mortality. TRIAL REGISTRATION NUMBER: NCT02482896.

Falls in elderly patients are not treated according to national recommendations.

INTRODUCTION: The aim of this study was to evaluate health professionals' compliance with recommendations from the Danish Health Authority (DHA) concerning falls, to study the prevalence of acute hospital visits due to falls, and to compare characteristics of fall patients in two geographically and socioeconomically different areas of Denmark. METHODS: The study was conducted in the emergency departments (ED) of Slagelse Hospital (SH) and Nykøbing Falster Hospital (NFH), both located in Denmark. Included were individuals > 50 years visiting the EDs from January 1 to March 31, 2014 who reported a fall. Information concerning demographic data and comorbidity in fall patients was retrieved from the medical records of the patients. RESULTS: A total of 2,664 individuals > 50 years visited the EDs during the study period. In all, 1,100 individuals (41.2%) reported a fall. In the NFH 236 (44%) and in the SH 223 (39%) of the fall patients had a fracture (p = 0.049). Patients in the more socioeconomically deprived area covered by the NFH were younger and had higher fracture and heart failure rates. Only 2% of the medical records contained answers to all four questions recommended by the DHA for risk screening in fall patients. The number of medical records containing answers to any of the four questions ranged from 17.5% to 25.8%. CONCLUSIONS: Only few fall patients were screened according to DHA recommendations. ED staff´s adherence to guidelines concerning fall risk assessment is poor. Fall patients in a socioeconomically deprived area were younger and had higher fracture and heart failure incidences. FUNDING: This study received funding from the public Regional Research Foundation, Region Zealand, Denmark. TRIAL REGISTRATION: not relevant.