Dual COX-2 and 15-LOX inhibition study of novel 4-arylidine-2-mercapto-1-phenyl-1H-imidazolidin-5(4H)-ones: Design, synthesis, docking, and anti-inflammatory activity.

Novel arylidene-5(4H)-imidazolone derivatives 4a-r were designed and evaluated as multidrug-directed ligands, that is, inflammatory, proinflammatory mediators, and reactive oxygen species (ROS) inhibitors. All of the tested compounds showed cyclooxygenase (COX)-1 inhibitory effect more than celecoxib and less than indomethacin and also demonstrated an improved inhibitory activity against 15-lipoxygenase (15-LOX). Compounds 4f, 4l, and 4p exhibited COX-2 selectivity comparable to that of celecoxib, while 4k was the most selective COX-2 inhibitor. Interestingly, the screened results showed that compound 4k exhibited a superior inhibition effect against 15-LOX and was found to be the most selective COX-2 inhibitor over celecoxib, whereas compound 4f showed promising COX-2 and 15-LOX inhibitory activities besides its inhibitory effect against ROS production and its lowering effect of both tumor necrosis factor-α and interleukin-6 levels by ∼80%. Moreover, compound 4f attenuated the lipopolysaccharide-mediated increase in NF-κB activation in RAW 264.7 macrophages. The preferred binding affinity of these molecules was confirmed by docking studies. We conclude that arylidene-5(4H)-imidazolone scaffolds provide promising hits for developing new synthons with anti-inflammatory and antioxidant activities.

The impact of functional status on LOS and readmission in older patients in geriatrics department: a cohort study.

BACKGROUND: Length of hospital stay (LOS) and readmission are important outcomes for older inpatients. The association between functional status on admission and outcomes has not been well investigated in Chinese elderly. OBJECTIVES: To detect the impact of function impairments on LOS and 90-day readmission in a population of Chinese elderly inpatients. METHODS: This is a prospective cohort study. All new patients over 60 years in geriatrics department of a university hospital in Western China from June to August 2016 were enrolled. Activities of daily living (ADL) and Instrumental ADL (IADL) on admission were evaluated with Barthel Index and Lawton IADL. Outcomes were LOS and 90-day readmission. LOS was calculated as the total days of hospital stay. Readmission was investigated through telephone interviews after discharge. Pearson Chi-square test was used to detect the associations. Binary logistic regression was used to detect the association of function status on admission with LOS and readmission. RESULTS: A total of 225 patients were enrolled. Mean age 82.41 (± 7.316; 63-99), 31.1% were females. Overall, 64.9% of the patients were hospitalized longer than 14 days and 33.30% experienced a 90-day readmission. Following an adjustment for age, gender, marital status, education level, smoking, alcohol, nutrition status, and admission location, the binary logistic regression models showed that both ADL impairment (OR 2.03; 95% CI 1.06-3.87) and IADL impairment (OR 2.54; 95% CI 1.28-5.01) were independent predictors for LOS. ADL impairment was an independent predictor for 90-day readmission (OR 2.26; 95% CI 1.14-4.47), while IADL impairment was not associated with readmission (OR 1.43; 95% CI 0.68-3.02). CONCLUSION: Functional status on admission is the predictor of LOS and 90-day readmission in Chinese older inpatients from the geriatric department of a university hospital.

Use of an expert panel to identify domains and indicators of delirium severity.

PURPOSE: Our purpose was to create a content domain framework for delirium severity to inform item development for a new instrument to measure delirium severity. METHODS: We used an established, multi-stage instrument development process during which expert panelists discussed best approaches to measure delirium severity and identified related content domains. We conducted this work as part of the Better ASsessment of ILlness (BASIL) study, a prospective, observational study aimed at developing and testing measures of delirium severity. Our interdisciplinary expert panel consisted of twelve national delirium experts and four expert members of the core research group. Over a one-month period, experts participated in two rounds of review. RESULTS: Experts recommended that the construct of delirium severity should reflect both the phenomena and the impact of delirium to create an accurate, patient-centered instrument useful to interdisciplinary clinicians and family caregivers. Final content domains were Cognitive, Level of consciousness, Inattention, Psychiatric-Behavioral, Emotional dysregulation, Psychomotor features, and Functional. Themes debated by experts included reconciling clinical geriatrics and psychiatric content, mapping symptoms to one specific domain, and accurate capture of unclear clinical presentations. CONCLUSIONS: We believe this work represents the first application of instrument development science to delirium. The identified content domains are inclusive of various, wide-ranging domains of delirium severity and are reflective of a consistent framework that relates delirium severity to potential clinical outcomes. Our content domain framework provides a foundation for development of delirium severity instruments that can help improve care and quality of life for patients with delirium.

Refining Delirium: A Transtheoretical Model of Delirium Disorder with Preliminary Neurophysiologic Subtypes.

The development of delirium indicates neurophysiologic disruption and predicts unfavorable outcomes. This relationship between delirium and its outcomes has inspired a generation of studies aimed at identifying, predicting, and preventing both delirium and its associated sequelae. Despite this, evidence on delirium prevention and management remains limited. No medication is approved for the prevention or treatment of delirium or for its associated psychiatric symptoms. This unmet need for effective delirium treatment calls for a refined approach. First, we explain why a one-size-fits-all approach based on a unitary biological model of delirium has contributed to variance in delirium studies and prevents further advance in the field. Next, in parallel with the shift from dementia to "major neurocognitive disorder," we propose a transtheoretical model of "delirium disorder" composed of interactive elements-precipitant, neurophysiology, delirium phenotype, and associated psychiatric symptoms. We explore how these relate both to the biopsychosocial factors that promote healthy cognition ("procognitive factors") and to consequent neuropathologic sequelae. Finally, we outline a preliminary delirium typology of specific neurophysiologic disturbances. Our model of delirium disorder offers several avenues for novel insights and clinical advance: it univocally differentiates delirium disorder from the phenotype of delirium, highlights delirium neurophysiology as a treatment target, separates the core features of delirium from associated psychiatric symptoms, suggests how procognitive factors influence the core elements of delirium disorder, and makes intuitive predictions about how delirium disorder leads to neuropathologic sequelae and cognitive impairment. Ultimately, this model opens several avenues for modern neuroscience to unravel this disease of antiquity.

Comparison of procalcitonin, a potentially new inflammatory biomarker of frailty, to interleukin-6 and C-reactive protein among older Chinese hospitalized patients.

AIM: Procalcitonin (PCT) has predictive value for patients with infectious diseases, but has not been studied in frailty. The purpose of this study was to compare PCT to two other inflammatory biomarkers [interleukin-6 (IL-6)] and C-reactive protein (CRP) in their association with frailty among older hospitalized patients. METHODS: Retrospective study of inpatients (June-December, 2016), who had all three biomarkers measured within 24 h of admission. Frailty was defined according to the Chinese version of a validated frailty scale. Due to the association of biomarkers with infection, we divided patients into "non-infected" (no pneumonia or other infections) and "pneumonia" (using standard criteria) groups. RESULTS: Of 435 patients (mean age 81.6 ± 8.6 years), 181 (41.6%) were designated the non-infected group and 254 (58.4%) the pneumonia group. Prevalence of frailty in the non-infected group was 32.0% (58/181) and frailty (univariate analysis) was associated with higher PCT and IL-6 levels but not CRP. Prevalence of frailty in the pneumonia group was 40.2% (102/254) and frailty was associated with all three biomarkers. In multivariable analysis adjusting for age, gender, smoking, alcohol use, hemoglobin, albumin, neutrophils and creatinine, PCT (not IL-6 and CRP) was associated with frailty in the non-infected group (OR = 5.244; 95% CI, 1.622-16.947; P = 0.006) and none of the biomarkers were associated with frailty in the pneumonia group. CONCLUSIONS: Although the study is limited due to the retrospective methods, PCT but not IL-6 or CRP, was associated with frailty among older inpatients without infection. None of these biomarkers were associated with frailty among patients with pneumonia.

Do nutrients play a role in delirium?

PURPOSE OF REVIEW: This study will review the biologic roles of thiamine, niacin, folic acid, cobalamin, antioxidants, lipids, glucose, and water and their implications as contributors or causal agents in the development of delirium, particularly if deficiencies or excesses exist. RECENT FINDINGS: Knowledge on how overall nutritional status and individual nutrients predispose or directly lead to the development of delirium is currently very limited. Most studies in the area of nutrition and cognition still describe mental status changes using the term dementia and do not specifically address nutrition and delirium. However, as the brain pathophysiology that accompanies delirium has been furthered elucidated, it has become clear that nutritional imbalances can lead to these same physiologic changes in neuronal tissue. SUMMARY: Delirium, characterized by an acute change in mental status along with diminished awareness and attention and disturbances in memory, language, or perception, confers high rates of morbidity and mortality and can be difficult to both diagnose and treat. Although the cause of delirium is often multifactorial, nutritional status and nutrients may play a role in predisposing or directly causing this acute cognitive dysfunction. Many nutritional deficiencies or excesses (i.e., B vitamins, antioxidants, glucose, water, lipids) have been shown to alter the way one thinks and restoring the balance in many of these nutrients can lead to resolution of delirium.

The effect of increased physical activity on pulmonary diffusing capacity in unfit women.

The purpose of the study was to determine whether short-term high-intensity aerobic interval training improves resting pulmonary diffusing capacity for nitric oxide (DLNO) and carbon monoxide (DLCO). Twenty-eight sedentary women [mean (SD) age 32 (11) years, body mass index 24.3 (5.7) kg m(-2)] were randomly assigned to either a self-directed moderate-intensity physical activity (n = 14) group or a supervised high-intensity aerobic interval training group (n = 14). The moderate physical activity group and the aerobic interval training group increased weekly physical activity energy expenditure by 800 and 1600 kcal week(-1), respectively. After 6 weeks, aerobic capacity increased to a similar exent in both groups (mean improvement 8%, effect size 0.39). The DLNO, but not DLCO, increased to a similar extent in both groups, by 4% or 3.0 (5.7) [95% confidence interval 0.8, 5.2] ml min(-1) mmHg(-1) m(-2) from pre- to post-training (effect size 0.27). There was no correlation between the change in aerobic capacity and the change in DLNO (P > 0.05) or between the change in aerobic capacity and the change in total weekly physical activity energy expenditure (P > 0.05). Interval training does not provide additional improvements in DLNO or aerobic capacity compared with self-directed moderate-intensity physical activity (4-6 metabolic equivalent tasks, 800 kcal week(-1), for 6 weeks) in unfit women. Despite the slight improvement in both DLNO and aerobic capacity, true meaningful physiological changes in these parameters remain questionable.

Implementation of a national monitoring programme of Campylobacter in Irish broilers to measure progress of on-farm and primary processing control measures.

BACKGROUND: Campylobacter is the most common food-borne pathogen in the European Union. In 2018, the crude incidence rate in Ireland was 63.6 per 100,000 population. Chicken is considered an important source of infection for humans. In 2015, the Campylobacter Stakeholders' Group (CSG) was established to reduce Campylobacter contamination levels in Irish broiler flocks. AIMS: This work aimed to describe the Campylobacter monitoring programme that was established by the CSG, to analyse the results of this testing between 2019 and 2022, and to assess progress. METHODS AND RESULTS: This paper describes the monitoring programme that was established by the CSG, which harmonized Campylobacter enumeration testing across all Irish broiler processors and allowed comparability of results for trend analysis. An analysis of the 2019-2022 data is presented here and compared to previous studies of Campylobacter levels in Irish broilers. An analysis of the 2019-2022 data showed a significant reduction in levels in both caeca and neck skin when the results from 2022 were compared to those from 2019 to 2020. Campylobacter spp. were detected in 37% of caecal samples from first depopulation (pre-thin) broilers and 30% of neck skin samples in 2022, with just 4% of carcases (in neck skin samples) with ≥1000 colony-forming units per gram detected in 2022. Campylobacter levels detected in Irish broilers, in the present monitoring programme were less than those reported in previous studies in both caecal and carcase samples, although not directly comparable for statistical significance because of differences in study methods. CONCLUSIONS: The cooperation between stakeholders and regulators of the Irish broiler chicken industry over the past decade has facilitated a coordinated approach to monitoring of Campylobacter levels in broilers, and implementation of control measures. This has enabled a steady reduction in the levels of Campylobacter in Irish chicken.

15-Lipoxygenase-1-mediated metabolism of docosahexaenoic acid is required for syndecan-1 signaling and apoptosis in prostate cancer cells.

Fatty acid metabolism impacts multiple intracellular signaling pathways in many cell types, but its role in prostate cancer cells is still unclear. Our previous studies have shown that the n-3 polyunsaturated fatty acid docosahexaenoic acid (DHA) induces apoptosis in human prostate cancer cells by a syndecan-1 (SDC-1)-dependent mechanism. Here, we examined the contribution of lipoxygenase (LOX)- and cyclooxygenase (COX)-mediated DHA metabolism to this effect. Pan-LOX inhibitor (nordihydroguaiaretic acid), 15-LOX inhibitor (luteolin) or 15/12-LOX inhibitor (baicalein) blocked the induced effect of DHA on SDC-1 expression and apoptosis in human prostate cancer cells, whereas 5-LOX inhibitor, AA861, was ineffective. Human prostate cancer cells lines (PC3, LNCaP and DU145 cells) expressed two 15-LOX isoforms, 15-LOX-1 and 15-LOX-2, with higher 15-LOX-1 and lower 15-LOX-2 expressions compared with human epithelial prostate cells. Knockdown of 15-LOX-1 blocked the effect of DHA on SDC-1 expression and caspase-3 activity, whereas silencing 15-LOX-2, 5-LOX, COX-1, COX-2 or 12-LOX had no effect. Moreover, the ability of DHA to inhibit the activity of the PDK/Akt (T308) signaling pathway was abrogated by silencing 15-LOX-1. These findings demonstrate that 15-LOX-1-mediated metabolism of DHA is required for it to upregulate SDC-1 and trigger the signaling pathway that elicits apoptosis in prostate cancer cells.

Delirium in the elderly.

Delirium is an acute and common problem often affecting frail and older persons in the acute care hospital, but can develop in any setting. It is associated with serious complications but can also be treatable if diagnosed early and managed properly. Preventive measures should be implemented in high risk patients, such as those with malnutrition, polypharmacy, infections, previous delirium, or dementia. Despite precautions, delirium is unavoidable in some cases and clinicians should be familiar with the typical features and varied presentations of this condition. Diagnosing delirium can be based on the DSM criteria, though multiple useful screening tools exist. Since delirium is almost always triggered by an underlying condition, an aggressive search for the causative insult(s) is essential in order that a targeted intervention be started promptly. Although there is neither any medication approved by the FDA for the treatment of delirium nor any robust evidence supporting the benefit of medications, there is general consensus that drug intervention can be attempted when non-pharmacological interventions have failed.

Changing Hospital Care For Older Adults: The Case for Geriatric Hospitals in the United States.

Hospital care of frail older adults is far from optimal. Although some geriatric models of care have been shown to improve outcomes, the effect size is small and models are difficult to fully implement, sustain and replicate. The two root causes for these shortcomings are competing interests (high revenue generating diseases, procedures and surgeries) and current hospital cultures (for example a culture of safety that emphasizes bed alarms and immobility rather than frequent ambulation). Geriatric hospitals would be hospitals completely dedicated to the care of frail older patients, a group which is most vulnerable to the negative consequences of a hospitalization. They would differ from a typical adult hospital because they could implement evidence based principles of successful geriatric models of care on a hospital wide basis, which would make them sustainable and allow for scaling up of proven outcomes. Innovative structural designs, unachievable in a typical adult hospital, would enhance mobility while maintaining safety. Financial viability and stability would be a challenge but should be feasible, likely through affiliation with larger health care systems with other hospitals because of cost savings associated with geriatric models of care (decreased length of stay, increased likelihood of discharge home, without increasing costs).

Association between body mass index and cognitive function among Chinese nonagenarians/centenarians.

AIMS: We examined the individual association between body mass index (BMI) and cognitive function among the very elderly. METHODS: The present study analyzed data from a survey that was conducted on all residents aged 90 years or more from a district which had 2,311,709 inhabitants in 2005. The subjects were divided into 4 groups according to quartiles of BMI (<16.6, 16.6-18.9, 18.9-21.1 and >21.1), and according to classification criteria of underweight, normal weight, overweight and obesity in BMI (<18.5, 18.5-23.0, 23.0-27.5 and >27.5), respectively. RESULTS: The subjects included in the statistical analysis were 211 men and 427 women. Those in the 3rd quartile of BMI (18.9-21.1) had higher cognitive function scores (p < 0.001) and were less likely to present possible dementia (p = 0.016) than the others. However, there was no difference in cognitive function scores (p = 0.350) or prevalence of possible dementia (p = 0.263) among obesity, overweight, normal weight and underweight groups. CONCLUSIONS: Concerning longevity in Chinese, there is an association between BMI and cognitive function. BMI of around 20 (18.9-21.1) is associated with the lowest risk of prevalence of possible dementia and the highest cognitive function scores.

Novel translocation responses of cytosolic phospholipase A2alpha fluorescent proteins.

Cytosolic phospholipase A2 (cPLA2)alpha responds to the rise in cytosolic Ca2+ ([Ca2+]i) attending cell stimulation by moving to intracellular membranes, releasing arachidonic acid (AA) from these membranes, and thereby initiating the synthesis of various lipid mediators. Under some conditions, however, cPLA2alpha translocation occurs without any corresponding changes in [Ca2+]i. The signal for such responses has not been identified. Using confocal microscopy to track fluorescent proteins fused to cPLA2alpha or cPLA2alpha's C2 domain, we find that AA mimics Ca2+ ionophores in stimulating cPLA(2)alpha translocations to the perinuclear ER and to a novel site, the lipid body. Unlike the ionophores, AA acted independently of [Ca2+](i) rises and did not translocate the proteins to the Golgi. AA's action did not involve its metabolism to eicosanoids or acylation into cellular lipids. Receptor agonists also stimulated translocations targeting lipid bodies. We propose that AA is a signal for Ca2+-independent cPLA2alpha translocation and that lipid bodies are common targets of cPLA2alpha and contributors to stimulus-induced lipid mediator synthesis.

Association of cognitive impairment with serum lipid/lipoprotein among Chinese nonagenarians and centenarians.

The association of cognitive impairment with abnormal levels of serum lipid/lipoprotein in the elderly, in whom there are differences between the old aged 65-84 years and the oldest old aged 85 years or above, has been confirmed by previous studies. However, there are no relevant data from a Chinese oldest old population. In the present study, we observed an association of cognitive impairment with abnormal levels of serum lipid/lipoprotein among very old people using a Chinese cohort aged 90-108 years. The population included 709 unrelated Chinese nonagenarians and centenarians (67.8% women, mean age 93.8 years). The mean score of cognitive function (measured with the 30-item Mini-Mental State Examination, MMSE) was 14.9 (SD 6.0). Comparing abnormal with normal levels of serum lipid/lipoprotein (including triglycerides, total cholesterol, high-density lipoprotein and low-density lipoprotein), in both genders, the odds ratio of cognitive impairment was statistically insignificant. There were no significant differences in levels of lipid/lipoprotein between subjects with and without cognitive impairment. Pearson correlation showed that MMSE scores were not significantly correlated with levels of lipid/lipoprotein. In summary, we found that levels of serum lipid/lipoprotein were not directly correlated with cognitive impairment among Chinese nonagenarians and centenarians.

The relationship between terrorism and distress and drinking: two years after September 11, 2001.

This study examined: 1) the prevalence of negative beliefs related to terrorism and 2) whether these beliefs were related to distress and drinking. Respondents (N = 1453) in a five-wave longitudinal cohort study sampled from a United States university workplace were surveyed by mail between 1996 and 2003. Instruments assessed were: negative beliefs related to 9/11/01, distress (depression, anxiety, somatization, PTSD [post-traumatic stress disorder]), and drinking (frequency, quantity, escapist motives, binge drinking, drinking to intoxication, and problem-related drinking). Regression analyses examined relationships between beliefs and mental health. A sizable percentage of respondents experienced terrorism-related negative beliefs. Higher negative belief scores were related to greater distress and problematic drinking in 2003, controlling for sociodemographic variables and (in most cases) pre-9/11 distress and drinking. Study limitations were noted and future research was recommended.

Insomnia among hospitalized older persons.

Among hospitalized older persons, rates of insomnia are alarmingly high, as is evident by the high rates of use of sedative-hypnotic drugs, ranging from 31% to 88%. Insomnia among hospitalized patients may represent undiagnosed sleep disorders, underlying medical problems, and underlying psychiatric problems. Causes of insomnia can be intrinsic or extrinsic. In the intensive care unit, which is one of the most studied areas of the hospital related to insomnia, most studies using polysomnography monitoring have shown that although sleep times seem normal (about 7&8 hours per night), no patients have normal sleep patterns. There is evidence supporting the use of nonpharmacologic interventions, which are preferable to the use of sedating drugs because of the risk associated with their use.

Three-dimensional simulation of anisotropic cell-driven collagen gel compaction.

Tissue equivalents (TEs), formed by entrapping cells in a collagen gel, are an important model system for studying cell behavior. We have previously (Barocas and Tranquillo in J Biomech Eng 117:161-170, 1997a) developed an anisotropic biphasic theory of TE mechanics, which comprises five coupled partial differential equations describing interaction among cells and collagen fibers in the TE. The model equations, previously solved in one or two dimensions, were solved in three dimensions using an adaptive finite-element platform. The model was applied to three systems: a rectangular isometric cell traction assay, an otherwise- acellular gel containing two islands of cells, and an idealized tissue-engineered cardiac valve leaflet. In the first two cases, published experimental data were available for comparison, and the model results were consistent with the experimental observations. Fibers and cells aligned in the fixed direction in the isometric assay, and a region of strong fiber alignment arose between the two cell islands. For the valve problem, the alignment predicted by the model was generally similar to that observed experimentally, but an asymmetry in the experiment was not captured by the model.

Transformation of a Geriatric Department in China.

China has the world's largest elderly population, and the oldest-old population, with a current disability rate greater than 50%, will triple in the next 35 years. The field of geriatrics is young, because almost all geriatric departments were established after 2000, and so faces many challenges. Management of diseases and hospital care is the focus. Senior physicians were trained in other subspecialties, such as pulmonary or cardiology, and junior physicians entered geriatrics departments as masters or doctorate students after medical school. The inadequacy of post-acute and long-term care facilities has caused long hospital stays. There are no national systematic geriatric training programs, national board examinations, or qualifications in geriatrics. These challenges were used as a framework for guiding changes in the Department of Geriatrics at West China Hospital, Sichuan University. These changes have included international experiences and collaboration for physicians and nurses, revision of departmental conferences, and special training for a unique group of caregivers called hugong (untrained caregivers hired by families to be at the bedside of hospitalized individuals). The most significant yet challenging part of the transformation has been to develop and modify Western-based geriatric models of care (e.g., Acute Care of the Elderly unit, delirium prevention and management models, palliative care). Lastly, the department established Tianxia (in the sky) Doctors, an internet-based platform to connect the department's interdisciplinary team to other hospitals, nursing institutions, home-based care service stations, community health service centers, and pharmacies throughout the region.

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. Geriatric departments in university-based hospitals primarily have developed out of a need to care for retired government officials and workers. There are no formal geriatric fellowships or national board certifications in geriatrics Health care is primarily based on fee for service. Not all elderly have healthcare insurance. Although costs of health care and medications are less expensive than in the United States, they are relatively high for lower- and middle-class Chinese and have increased more quickly than has the standard of living in the past 20 years. Family and community support for older people is strong in China. Some older people have one-to-one care from a baomu (literally "protection" (bao) "mother" (mu)), a type of live-in maid who also provides care for the older person. Some of the challenges facing China in the care of its aging population are how to increase geriatric research and training, how to care for the uninsured or underinsured, and how to handle the inevitable growth of disabled and frail older people.

Debating the Role of Arousal in Delirium Diagnosis: Should Delirium Diagnosis Be Inclusive or Restrictive?

Delirium is common in acute, postacute, and long-term care settings, and it can be difficult to recognize, especially without deliberate mental status evaluation. Because delirium typically presents with altered arousal and arousal can be assessed within a matter of seconds, routine assessment of arousal offers an efficient means of delirium screening. Nevertheless, impaired arousal often precludes formal assessment of attention and awareness, the cardinal features of delirium per the current Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Here we debate the relative merits of "ruling in" as delirious noncomatose patients with impaired arousal (inclusive approach) vs reserving delirium diagnosis to patients in whom diagnostic criteria can be elicited (restrictive approach). Inclusivism provides efficiency and may prevent missing or delaying delirium diagnosis. The restrictive approach challenges the utility of ruling such patients in as delirious and advocates for identifying mental states that directly inform clinical care. Both positions, however, firmly emphasize the value of routine clinical assessment of arousal.