Delirium screening in the emergency department: evaluation and intervention.

BACKGROUND: Between 8-17% of older adults, and up to 40% of those arriving from nursing homes, present with delirium upon admission to the Emergency Department (ED). However, this condition often remains undiagnosed by ED medical staff. We investigated the prevalence of delirium among patients aged 65 and older admitted to the ED and assessed the impact of a prospective study aimed at increasing awareness. METHODS: The study was structured into four phases: a "pre-intervention period" (T0); an "awareness period" (T1), during which information about delirium and its diagnosis was disseminated to ED staff; a "screening period" (T2), in which dedicated evaluators screened ED patients aged 65 and older; and a "post-intervention period" (T3), following the departure of the evaluators. Delirium screening was conducted using the Brief Confusion Assessment Method (bCAM) questionnaire. RESULTS: During the T0 and T1 periods, the rate of delirium diagnosed by ED staff was below 1%. The evaluators identified a delirium rate of 14.9% among the screened older adults during the T2 period, whereas the rate among those assessed by ED staff was between 1.6% and 1.9%. Following the evaluators' departure in the T3 period, the rate of delirium diagnosis decreased to 0.89%. CONCLUSIONS: This study underscores that a significant majority of older adult delirium cases remain undetected by ED staff. Despite efforts to increase awareness, the rate of diagnosis did not significantly improve. While the presence of dedicated delirium evaluators slightly increased the diagnosis rate among patients assessed by ED staff, this rate reverted to pre-intervention levels after the evaluators left. These findings emphasize the necessity of implementing mandatory delirium screening during ED triage and throughout the patient's stay.

The outcomes of treatment for homebound adults with complex medical conditions in a hospital-at-home unit in the southern district of Israel.

BACKGROUND: A model of hospital-at-home services called the Home Care Unit ("the unit") has been implemented in the southern region of the Clalit Healthcare Services in Israel. The aim of the present study was to characterize this service model. METHODS: A retrospective cross-over study. included homebound patients 65 years of age and above who were treated for at least one month in the framework of the unit, between 2013 and 2020. We compared the hospitalization rate, the number of hospital days, the number of emergency room visits, and the cost of hospitalization for the six-month period prior to admission to the unit, the period of treatment in the unit, and the six-month period following discharge from the unit. RESULTS: The study included 623 patients with a mean age of 83.7 ± 9.2 years with a mean Mini-mental State Examination (MMSE) score of 12.0 ± 10.2, a mean Charlson Comorbidity Index (CCI) of 3.7 ± 2.2 and a Barthel Index score of 23.9 ± 25.1. The main indications for admission to the unit were various geriatric syndromes (56.7%), acute functional decline (21.2%), and heart failure (12%). 22.8% died during the treatment period and 63.4% were discharged to ongoing treatment by their family doctor after their condition stabilized. Compared to the six months prior to admission to the unit there was a significant decrease (per patient per month) in the treatment period in the number of days of hospitalization (2.84 ± 4.35 vs. 1.7 ± 3.8 days, p < 0.001) and in the cost of hospitalization (1606 ± 2170 vs. 1066 ± 2082 USD, p < 0.001). CONCLUSIONS: Treatment of homebound adults with a high disease burden in the setting of a hospital-at-home unit can significantly reduce the number of hospital days and the cost of hospitalization. This model of service for homebound patients with multiple medical problems maintained a high level of care while reducing costs. The results support the widespread adoption of this service in the community to enable the healthcare system to respond to the growing population of elderly patients with medical complexity.

Discontinuation of benzodiazepines and Z-drugs in hospitalised population at the age of 60 and above. An open-label randomized controlled trial.

BACKGROUND: Treating insomnia with hypnotic drugs in elderly patients has many adverse effects. This study aims to assess the effect of two discontinuation methods of hypnotic drugs during acute hospitalization. METHODS: We conducted an open-label randomized controlled trial that included participants aged 60 and above taking benzodiazepines or Z-Drugs for at least 3 months as a treatment for insomnia and were admitted to the hospital. In the prospective arm, patients were randomly assigned into two intervention groups. In the Minimal Intervention (MI) group, patients received an explanation of the dangers of long-term treatment and a recommendation to stop the treatment. In the Tapering Down Intervention (TDI) group, in addition to the explanation, patients received a tapering down table. In the retrospective arm (control group), we examined the use of hypnotic drugs among hospitalized patients 3 months after hospitalization, similar to the patients in the prospective arm. RESULTS: 46 patients were enrolled in the MI group, 55 patients in the TDI group, and 114 patients in the control group. The mean age in the three groups was 75.0 ± 8.2, 75.9 ± 9.0, and 75.0 ± 7.9 years respectively (p = 0.85). After 3 months, seven (15.2%) of the patients in the MI group, 15 (27.3%) in the TD group, and 2 (1.8%) in the control group (p = 0.00003) were weaned from the hypnotic drugs treatment, without a significant difference between the intervention groups (p = 0.221). CONCLUSIONS: A short intervention during hospitalization results in a significant decrease in hypnotic drug use.

Handgrip Strength as a Predictor of Successful Rehabilitation After Hip Fracture in Patients 65 Years of Age and Above.

Purpose: It is important to identify factors associated with the outcome of rehabilitation after hip fracture as an aid to planning the rehabilitation framework and the future discharge of patients. Previous studies have shown that handgrip strength (HGS) is one of the factors associated with the success of rehabilitation. Materials and Methods: A retrospective study among patients 65 years of age and above who underwent surgical repair of a hip fracture followed by rehabilitation in the Geriatrics ward between September 2019 and December 2021. Successful rehabilitation was determined as Montebello Rehabilitation Factor Score Revised (MRFS-R) ≥50%. Associations were assessed between various sociodemographic and clinical variables, including HGS, and rehabilitation success. HGS was tested as a continuous and dichotomous variable, in accordance with various definitions of low muscle strength. Results: Data were collected for 173 patients. The mean age was 81.2 ± 7.2 years and 68.2% were women. In a logistic regression model only HGS, as a continuous variable, was independently associated with rehabilitation success, with each increase of 1 kg increasing the chance for successful rehabilitation by 6.8%. Conclusion: HGS is a simple tool for the planning of the rehabilitation process among patients with hip fracture.

Treatment outcomes of acute streptococcal tonsillitis according to antibiotic treatment. A retrospective analysis of 242,366 cases treated in the community.

BACKGROUND: Acute upper respiratory infections are the most common reason for primary physician visits in the community. This study investigated whether the type of antibiotic used to treat streptococcal tonsillitis can reduce the burden by affecting the number of additional visits. OBJECTIVES: To assess the effect of different antibiotic treatments for tonsillitis on the number of additional primary physician visits and the development of infectious or inflammatory sequels. METHODS: This retrospective study included first cases of culture-confirmed streptococcal tonsillitis (n = 242,366, 55.3% females, 57.6% aged 3-15 years) treated in primary clinics throughout Israel between the years 2010 and 2019. Primary outcomes were the number of additional primary physician visits, due to any cause or due to specific upper airway infections. Secondary outcomes were the number of developed complications, such as peritonsillar abscess, post-streptococcal glomerulonephritis, rheumatic fever, post-streptococcal arthritis, chorea and death. RESULTS: Compared to penicillin-V, adjusted incidence rate ratios (IRR) for additional primary physician visits at 30-days were highest for IM benzathine-benzylpenicillin (IRR = 1.46, CI 1.33-1.60, p < .001) and cephalosporin treatment (IRR = 1.27, CI 1.24-1.30, p < .001). Similar results were noted for visits due to specific diagnoses such as recurrent tonsillitis, otitis media and unspecified upper respiratory tract infection. Amoxicillin showed decreased adjusted odds ratio (aOR) of developing complications (aOR = 0.68, CI 0.52-0.89, p < .01 for any complication. aOR = 0.75, CI 0.55-1.02, p = .07 for peritonsillar or retropharyngeal abscess). CONCLUSION: Penicillin-V treatment is associated with fewer additional primary physician visits compared to other antibiotic treatments. Amoxicillin and penicillin-V are associated with fewer complications. These findings are limited by the retrospective nature of the study and lack of adjustment for illness severity. Further prospective studies may be warranted to validate results.

[PILOT PROGRAM OF HOME HOSPICE FOR OLDER PEOPLE WITH ADVANCED DEMENTIA].

INTRODUCTION: Dementia is a terminal illness and in an advanced stage it is suitable for palliative care. OBJECTIVES: To examine the results of a pilot program of home hospice for the elder patients with advanced dementia. METHODS: Patients aged 65 years and over who met the criteria for advanced dementia and palliative care were treated as part of the geriatric team-based home hospice program. The program included home visits by a multidisciplinary team that was available 24/7. During the program, special questionnaires are used to assess the patients' condition, the caregivers' burden and the caregivers' satisfaction with the treatment. RESULTS: Between August 2017 and July 2020, 44 patients were treated in hospice, the mean age was 86.1 ± 6.2 years and 26 (59%) of the patients were women. The average length of stay in the hospice was 129.4 ± 155.5 days (median 68 days) and most patients (36) died at home. The home hospice program leads to statistically significant improvement in the intensity of the behavioral and psychological effects of dementia, the severity of the pain and the intensity of the patients' suffering. In addition, there was a statistically significant decrease in the level of distress and the intensity of anxiety and depression of the family members. Almost all family members noted high satisfaction with end-of-life care. CONCLUSIONS: A home hospice program for patients with advanced dementia, based on a multidisciplinary geriatric team and the use of dedicated tools to evaluate the effectiveness of the intervention makes it possible to prevent the suffering of patients and their families and enable them to die in their preferred place. DISCUSSION: Home hospice is a worthy treatment alternative for terminally ill patients with advanced dementia who want to end their lives at home The home hospice care alleviates the patient's suffering, allows him/her to die in his/her preferred place and alleviates the distress of the family members, who express satisfaction from the treatment.

Cross-Sectional Study on Ethnic Differences in Occupational Injuries in Southern Israel-An Eight-Year Data analysis.

OBJECTIVE: To characterize and compare occupational injuries among population sectors in southern Israel and to evaluate their use of healthcare services and analgesic drugs. METHODS: Retrospective cross-sectional study. RESULTS: There were 100,000 occupational injuries among 70,037 insured individuals over the study period from January 1, 2009 to December 31, 2016. There was a large increase in occupational traffic injuries over this period. Compared to the veteran Jewish population, Bedouin Arabs, new immigrants and foreign workers had significantly lower rates of use of ambulatory services and imaging tests ( P < 0.001). Arabs had significantly higher odds for recurrent occupational injuries (OR = 1.29, P < 0.001), and being a new immigrant protected against recurrent injuries (OR = 0.70, P < 0.001). CONCLUSIONS: Medical staffs should invest greater effort into explaining the spectrum of diagnostic and treatment options for vulnerable groups as well as workers' rights.

Ageism, Aging Anxiety, and Death and Dying Anxiety Among Doctors and Nurses.

Ageism is an important phenomenon that affects individuals and how society relates to older adults. It is important to evaluate ageism in the medical staff because of its potential effect on treatment for older adults. A cross-sectional study to assess the negative attitudes of doctors and nurses toward older adults was conducted using the Fraboni Scale of Ageism (FSA), a method for evaluating attitudes toward ageism in medical teams. Additional variables associated with ageism such as aging anxiety, and death and dying anxiety were also assessed. The study population included doctors and nurses working in a large university hospital or in community clinics in southern Israel. In all, 431 questionnaires were collected, 203 from the hospital (47.5%) and 224 from the community (52.5%). Of these, 216 (50.1%) were from doctors and 215 (49.9%) from nurses. The mean ageism score in the FSA was 2.8. In a linear regression model, doctors were less ageist than nurses; ageism was directly associated with aging anxiety, and dying anxiety, and was inversely associated with death anxiety. Among doctors, prominent ageist attitudes were directly associated with aging and dying anxiety, inversely associated with graduation from medical school in Israel, and death anxiety. Among nurses, prominent ageism attitudes were directly associated with dying anxiety and inversely associated with work in the hospital. Ageist attitudes were found among doctors and nurses in both the hospital and community clinics. The results emphasize the need to raise awareness of ageism in medical teams and to include this subject in professional training programs designed to reduce its prevalence.

Ageism Among Physicians and Nurses in Russia.

The phenomenon of ageism has been studied extensively in the Western world, but there is only a small number of studies among medical staff in Russia. The aim of this study was to assess the prevalence of ageism and to identify variables that can explain ageism in a sample of physicians and nurses in Russia. This is a prospective cross-sectional study of physicians and nurses who participated in a training course in the years 2016-2018 in Russia. Data collected before the start of training included the Fraboni scale of ageism (FSA) questionnaire, and sociodemographic characteristics including age, gender, profession, professional seniority, place of work, and number of older adults treated by the study participant over the past half year. In total, 903 physicians and nurses participated in the study. The mean FSA score was 2.75 ± 0.49, which indicates a moderate degree of ageism. There was a trend to higher scores among nurses compared with physicians (2.78 ± 0.50 vs. 2.76 ± 0.48, p < 0.465). There was a weak, but statistically significant, correlation between ageism and age (r = 0.157, p < 0.0001), professional seniority (r = 0.098, p < 0.003), and the number of older adult patients treated by the participant over the prior half year (r = 0.075, p < 0.025). There were no differences in other characteristics including gender, profession, work setting, or serving as main caregiver for a family member and the magnitude of ageism. The phenomenon of ageism exists among physicians and nurses in Russia. Older participants with greater professional seniority and a larger number of older patients had stronger ageism attitudes.

Methylphenidate for Mild Cognitive Impairment: An Exploratory 3-Day, Randomized, Double-Blind, Placebo-Controlled Trial.

Background: To evaluate the efficacy, safety and tolerability of methylphenidate (MPH) for cognitive function in older patients with mild cognitive impairment (MCI). Methods: Male and female subjects aged 65 years and older with a clinical diagnosis MCI were included in an exploratory randomized, double-blind, placebo-controlled trial. Eligible subjects were assigned to either treatment with immediate-release MPH or placebo. The active compound was administered in an increasing-dose stepwise fashion, namely 10 mg MPH on day 1, 20 mg on day 2, and 30 mg on day 3. Subjects remained under observation for 4 h following drug administration and were monitored for changes in blood pressure and for adverse events. Cognitive outcome measures included the Montreal Cognitive Assessment (MoCA) and the Neurotrax Mindstreams computerized cognitive assessment battery. Results: Of 17 subjects enrolled, 15 subjects completed the study, 7 in the active MPH group and 8 in the placebo group. The average age of the participants was 76.1 ± 6.6 years and 10 (66.7%) were men. Following the final dose a significant benefit on memory (predominantly non-verbal memory) was found in the MPH group. While 12 adverse events were reported, they were all rated as mild to moderate. Conclusions: Our finding of modest beneficial effects of MPH on memory tests in older subjects with MCI in this exploratory study is of interest and should be investigated in further studies.

The Association Between Comorbidity, Frailty, and Outdoor Mobility Loss Among Community-Dwelling Individuals 60 Years of Age and Above in Moscow.

To determine the prognostic value of frailty and comorbidity for outdoor mobility loss and mortality in the elderly. The retrospective study was conducted among outpatients aged ≥60 years. Patients with ≥3 chronic illnesses were treated by doctors who had undergone a 72-hour geriatric training. The outdoor low-mobility group comprised patients who failed to visit a doctor because of decreased outdoor mobility during the 3-year follow-up period. The outdoor high-mobility group comprised participants with no outdoor mobility loss. 5678 patients with a mean age of 71.0 ± 0.1 years were included in the study. The risk of outdoor mobility loss rose by 4% per year with men developing it 30% more than women. The effect of frailty was of particular importance because it increased the risk of developing outdoor mobility loss by 70%. Comorbidity was not associated with a higher risk of outdoor mobility loss, but the investigators did not take into account all possible illnesses, or the severity of disease. The loss of outdoor mobility was associated with increase in mortality. Early detection of frailty can help predict outdoor mobility loss and could reduce mortality among older people.

Intensive Inpatient vs. Home-Based Rehabilitation After Hip Fracture in the Elderly Population.

Background: As the population ages, the rate of hip fractures and the need for rehabilitation increases. Home-based rehabilitation (HBR) is an alternative to classic inpatient rehabilitation (IR), which is an expensive framework with non-negligible risks. Methods: A retrospective study of patients 65 years and above following surgery to repair a hip fracture who underwent HBR or IR between 2016 and 2019. The two rehabilitation frameworks were compared for rehabilitation outcome and factors predicting successful rehabilitation. The outcome was determined with the Montebello Rehabilitation Factor Score-Revised (MRFS-R). Results: Data were collected for 235 patients over 3 years. The mean age was 81.3 ± 8.0 and 172 (73.3%) were women. Of these, 138 underwent IR and 97 HBR. The HBR group had better family support and fewer lived alone. There were also differences in the type of fracture and surgery. The medical condition of the IR group was more complex, as reflected in a higher Charlson's comorbidity scores, higher rates for delirium and more infectious complications, a lower Norton score, lower serum hemoglobin, and albumin levels, and higher serum creatinine and urea levels. It also had a more significant functional decline after surgery and required a longer rehabilitation period. However, no difference was found in the rehabilitation outcomes between the two groups (MRFS-R ≥ 50). The independent predictors for rehabilitation in the IR group were serum albumin level, comorbidity, and cognitive state. There were no independent predictors in the HBR group. Conclusions: In this retrospective study, there was no significant difference in short-term rehabilitation outcomes between the HBR and IR groups event though the patients in the IR group were medically more complex. This result should be taken into account when planning rehabilitation services after hip fracture and tailoring rehabilitation frameworks to patients.

Delirium in Internal Medicine Departments in a Tertiary Hospital in Israel: Occurrence, Detection Rates, Risk Factors, and Outcomes.

Background: The aim of the study was to assess the occurrence rate of delirium among elderly hospitalized patients in the medicine wards of a large tertiary hospital, to identify risk factors, and to evaluate the diagnostic rate for delirium among the medical teams. Methods: A 3-month prospective study of patients 65 years of age and above in three medicine wards: in two wards patients were examined by trained study team members using the Confusion Assessment Method (CAM), while the third was a control ward where CAM was not administered. The third ward served to control for the effect of the presence of investigators in the other wards as a potential confounding factor. Based on the results of this assessment patients were defined as suffering from subsyndromal delirium, full delirium (these two groups were later combined into an "any symptoms of delirium" group), and no delirium. The rate of diagnosis by the medical team was obtained from the electronic medical records. Results: The full delirium rate was 5.1%, the rate of subsyndromal delirium was 14.6%, and the rate of any symptoms of delirium was 19.6%. Absence of a partner, pain, anemia, hyponatremia, hypocalcemia, and the use of drugs with an anticholinergic burden were factors for any symptoms of delirium as well as for subsyndromal delirium. Subsyndromal delirium and any symptoms of delirium were associated with a reduced chance of being discharged to home and a higher 3-month mortality rate. A diagnosis of delirium was found in only 19.4% of the patients with any symptoms of delirium in the medical records. Conclusions: Delirium is a common problem among elderly hospitalized patients, but it is diagnosed sub-optimally by the medical team. There is a need for further training of the medical teams and implementation of delirium assessment as part of the ward's routine.

Validation of the Russian Version of the MoCA Test as a Cognitive Screening Instrument in Cognitively Asymptomatic Older Individuals and Those With Mild Cognitive Impairment.

Background: Cognitive impairment is a common condition in older people, and age-related cognitive symptoms may progress to Mild Cognitive Impairment and Dementia. Physical exercise and cognitive training may be useful in maintaining cognitive function, and those developing impaired cognitive function should be advised to plan for the future. The MoCA test is a useful cognitive screening instrument, but the Russian version of this test has not yet been validated. The aim of the present study was to validate the Russian version of the MoCA test. Methods: The study population included 160 residents of Israel aged 65 years and older with Russian as their mother tongue, 80 of whom were cognitively asymptomatic (AC) and 80 with a clinical diagnosis of MCI. All participants underwent cognitive screening using the Russian version of the MoCA test (MoCA-Ru) as well as evaluation by means of a validated computerized cognitive assessment battery (Neurotrax). Results: The mean age of the study population was 78 ± 6.6 years and 123 (76.9%) were women. The MoCA-Ru score was higher in the AC group than in those with MCI (24.3 ± 3.74 vs. 20.2 ± 3.07, P < 0.0001). At a cutoff value of ≥25, sensitivity was 0.99 and specificity 0.54, with area under the curve (AUC) of 0.81. Conclusions: We found the Russian language version of the MoCA test to be a useful cognitive screening instrument for older people with mild cognitive impairment.

[FEMORAL HEAD FRACTURE IN PATIENTS 65 YEARS AND OLDER WITH ATRIAL FIBRILLATION: THE EFFECT OF ANTI-COAGULATION ON COMPLICATIONS AND PROGNOSIS].

BACKGROUND: Atrial fibrillation and hip fractures are common problems in elderly patients. Delay in the timing of surgical repair can lead to increased complications and anti-coagulation could be a reason for delay. OBJECTIVES: To assess morbidity and mortality in patients 65 years and older with atrial fibrillation (AF) and hip fracture in relation to the type of anti-coagulation. METHODS: A retrospective cross-sectional study of patients with AF and hip fracture aged 65 and older was conducted in a tertiary hospital. Data collected included co-morbidity, medical history, medications, the timing of surgery, thromboembolic events, estimated risk for stroke by CHADS2 score, for significant bleeding by HAS-BLED score and mortality rate for the six-month period following surgery. RESULTS: During the period 2014-2016, 186 patients 65 years and older with atrial fibrillation underwent surgical repair of a hip fracture, 113 (60.7%) women. The mean age was 81.9±7.1 years. Eighty-nine (47.8%) did not receive any anti-coagulation, 60 (32.3%) received new oral anticoagulants (NOAC), and 37 (19.9%) warfarin. There were no differences between these groups on pre-and post-operation burden of co-morbidity, timing of surgery, surgical delay, complication rate, or mortality rate during the six months following surgery. CONCLUSIONS: Anti-coagulation for patients 65 years and older with atrial fibrillation and hip fracture did not affect the timing of surgery or the rate of complications and mortality. Based on these results the concern over emergency surgery and its complications in patients with AF is not justified.

[REVIEW OF DECISION-MAKING CAPACITY (DMC) ASSESSMENT TOOLS FOR TREATMENT AMONG ELDERLY PATIENTS WITH COGNITIVE IMPAIRMENT].

INTRODUCTION: The need to evaluate decision-making capacity for treatment among patients over 65 with cognitive impairment has increased because of the ageing of the population. The inability to make decisions about treatment may be part of cognitive impairment and the prevalence of this phenomenon increases according to the age and severity of the cognitive impairment. The lack of a clear definition of the law regarding the assessment of the decision-making capacity for treatment, the lack of structured training as part of the formal medical education and the lack of uniformity in performing assessment of the decision-making capacity for treatment among physicians leads to many errors and inconsistencies in assessment. In addition to physicians' clinical judgement, additional tools have been developed that enable more accurate assessment of the decision-making capacity for treatment of the older patients. Enhancement of the knowledge of the medical staff on the issue of assessment of the decision-making capacity for treatment, together with encouraging the use of validated tools can reduce the rate of errors, evaluate all the components of decision-making capacity for treatment and help older people realize their constitutional rights and maintain individual autonomy. The current review will discuss existing tools for assessing the decision-making capacity for treatment among those aged over 65 with cognitive impairment.

Israel Ad Hoc COVID-19 Committee: Guidelines for Care of Older Persons During a Pandemic.

Early on, geriatricians in Israel viewed with increasing alarm the spread of coronavirus disease 2019 (COVID-19). It was clear that this viral disease exhibited a clear predilection for and danger to older persons. Informal contacts began with senior officials from the country's Ministry of Health, the Israel Medical Association, and the country's largest health fund; this was done to plan an approach to the possible coming storm. A group was formed, comprising three senior geriatricians, a former dean, a palliative care specialist, and a lawyer/ethicist. The members made every effort to ensure that their recommendations would be practical while at the same time taking into account the tenets of medical ethics. The committee's main task was to think through a workable approach because intensive care unit/ventilator resources may be far outstripped by those requiring such care. Recommendations included the approach to older persons both in the community and in long-term care institutions, a triage instrument, and palliative care. Patient autonomy was emphasized, with a strong recommendation for people of all ages to update their advance directives or, if they did not have any, to quickly draw them up. Considering the value of distributive justice, with respect to triage, a "soft utilitarian" approach was advocated with the main criteria being function and comorbidity. Although chronological age was rejected as a sole criterion, in the case of an overwhelming crisis, "biological age" would enter into the triage considerations, but only in the case of distinguishing between people with equal non-age-related deficits. The guideline emphasized that no matter what, in the spirit of beneficence, anyone who fell ill must receive active palliative care throughout the course of a COVD-19 infection but especially at the end of life. Furthermore, in the spirit of nonmaleficence, the frail, very old, and severely demented would be actively protected from dying on ventilation. J Am Geriatr Soc 68:1370-1375, 2020.

Randomized trial results of alerting primary clinicians to severe weight loss among older adults in the Low Indexes of Metabolism Intervention Trial part A.

AIM: To test whether alerting clinicians to severe weight loss in older patients leads to higher dietitian visit rates, to higher body mass index (BMI) levels and, mainly, to lower annual death risk. METHODS: The randomized controlled trial included patients aged ≥75 years, with BMI ≤23 kg/m2 that decreased ≥2 kg/m2 during the previous 2 years. All participants received usual care. Additionally, an email alert was sent only to clinicians of participants assigned to the email alert group. The follow-up period was 12 months. RESULTS: Among 706 participants (mean age 83 ± 6 years; mean baseline BMI 20.5 kg/m2 ), the BMI record was updated in 541 (77%) participants, and 123 participants died. Dietitian visits were reported for 22 patients (6%) in the email group (n = 362) and 14 patients (4%) in the control group (n = 344; OR 1.5, 95% CI 0.8-2.9; P = 0.24). Measured BMI were raised by a mean of 0.69 (95% CI 0.43-0.95) kg/m2 versus 0.79 (95% CI 0.48-1.1) kg/m2 (P = 0.63). A total of 77 patients (21%) died in the intervention group versus 47 (14%) in the control group (P = 0.008; number needed to harm = 13; 95% CI 7-43). CONCLUSIONS: In this trial, alerting clinical staff to severe weight loss in patients aged ≥75 years was not associated with higher visit rates to a dietitian or change in BMI, but was associated with a significantly higher death rate than usual clinical care. Geriatr Gerontol Int 2020; 20: 329-335.

Implementation of Geriatric Recommendations by Doctors: A Comparison of Models of Geriatric Assessment for Mobile and Home-Ridden Patients.

In the present study we assessed the rate of implementation of recommendations given following geriatric assessment for home-ridden patients; a retrospective review of medical records to evaluate the implementation of geriatric recommendations given to patients in the Home Geriatric Service (HGS) between 2015 and 2016. The patients were categorized into two groups: the HGS-clinic (HGS-C) group, in which the primary care physician was responsible for implementation of the recommendations, and the HGS-home care (HGS-H) group, in which the responsibility for implementation of the recommendations was on the geriatrician. The results were compared with the implementation of recommendations in other ambulatory models for mobile patients-Clinic-Based Geriatric Assessment Services (CBGAS). The study included 865 patients. The highest rate of implementation was in the HGS-H group (85.7%), compared with 66.6% in the HGS-C group and 52.7% in the CBGAS group (p < 0.0001). In the logistic regression model for prediction of patients with implementation rates above 75%, the only variable that entered the prediction model was affiliation with the HGS-H group (odds ratio [OR] = 4.8, 95% confidence interval [CI] 2.3-9.6, p < 0.0001) or the HGS-C group (OR = 1.7, 95% CI 1.0-2.9, p = 0.046). The implementation rate for geriatric recommendations is higher for home-ridden patients compared with mobile patients, with the maximum recommendation rate in the subgroup, where geriatricians implemented the recommendations themselves. These findings raise the possibility that the most successful model, in terms of the implementation of recommendations, is the model in which implementation is carried out by the same staff that conducted the assessment.

A Randomized Trial of Alerting to Low Glycated Hemoglobin Level in Older Adults: Results of the Low Indexes of Metabolism Intervention Trial B (LIMIT-B).

OBJECTIVES: The benefit of alerting clinical staff to low plasma glycated hemoglobin (HbA1c) in patients aged 75 years and older who receive antidiabetic drugs remains uncertain. DESIGN, SETTING, AND PARTICIPANTS: In a randomized controlled trial, 1684 patients with HbA1c ≤ 6.5% who received antidiabetic drugs were assigned to have an e-mail alert sent to their physician, and 1643 were assigned to have no such alert (control group). The primary outcome of the trial was annual death. Secondary outcomes included antidiabetic drug dose reduction and HbA1c change. RESULTS: In the first quarter, antidiabetic drug-defined daily doses were reduced on average by 10.4 ± 35.8 (16% ± 55%) in the intervention group and by 6.4 ± 36.1 (10% ± 56%) in the control group (difference -4.1 ± 1.2, 95% confidence interval [CI] -6.5 to -1.6; P = .001). Measured HbA1c levels were raised by a mean (± standard deviation) of 0.28 ± 0.77 in the intervention group and by 0.18 ± 0.57 in the control group (difference 0.10 ± 0.02, 95% CI -0.15 to -0.059, P < .001). One year after the alerts, 121 patients (7.2%) died in the intervention group and 107 patients (6.5%) died in the control group (relative risk 1.1, 95% CI 0.86-1.42; P = .44). CONCLUSIONS AND IMPLICATIONS: In this trial, alerting clinical staff to low HbA1c in patients aged 75 years and older treated with antidiabetic medicines was associated with mildly reduced antidiabetic doses and increased HbA1c but was not associated with a significant difference in survival rate compared with usual clinical care.