Delirium in geriatric patients.

Delirium is the most common acute disorder of cognitive function in older patients. Delirium is life threatening, often under-recognized, serious, and costly. The causes are multifactorial, with old age and neurocognitive disorders as the main risk factors. Etiologies are various and multifactorial, and often related to acute medical illness, adverse drug reactions, or medical complications. To date, diagnosis is clinically based, depending on the presence or absence of certain features. In view of the multifactorial etiology, multicomponent approaches seem most promising for facing patients' needs. Pharmacological intervention, neither for prevention nor for treatment, has been proven effective unanimously. This article reviews the current clinical practice for delirium in geriatric patients, including etiology, pathophysiology, diagnosis, prognosis, treatment, prevention, and outcomes.

Current evidence on the impact of medication optimization or pharmacological interventions on frailty or aspects of frailty: a systematic review of randomized controlled trials.

BACKGROUND: Frailty and adverse drug effects are linked in the fact that polypharmacy is correlated with the severity of frailty; however, a causal relation has not been proven in older people with clinically manifest frailty. METHODS: A literature search was performed in Medline to detect prospective randomized controlled trials (RCTs) testing the effects of pharmacological interventions or medication optimization in older frail adults on comprehensive frailty scores or partial aspects of frailty that were published from January 1998 to October 2019. RESULTS: Twenty-five studies were identified, 4 on comprehensive frailty scores and 21 on aspects of frailty. Two trials on comprehensive frailty scores showed positive results on frailty although the contribution of medication review in a multidimensional approach was unclear. In the studies on aspects related to frailty, ten individual drug interventions showed improvement in physical performance, muscle strength or body composition utilizing alfacalcidol, teriparatide, piroxicam, testosterone, recombinant human chorionic gonadotropin, or capromorelin. There were no studies examining negative effects of drugs on frailty. CONCLUSION: So far, data on a causal relationship between drugs and frailty are inconclusive or related to single-drug interventions on partial aspects of frailty. There is a clear need for RCTs on this topic that should be based on a comprehensive, internationally consistent and thus reproducible concept of frailty assessment.

DEL-FINE: a new tool for assessing the delirogenic properties of drugs of relevance for European pharmacotherapy.

This article presents a list of potentially delirogenic properties of drugs that are currently of relevance to drug therapy in Europe, which was created through a Delphi process including experts from professions relevant to diagnosis and treatment of delirium. The Diagnostic and Statistical Manual of Mental Disorders 5 (DSM 5) defines delirium as a disturbance in attention, awareness and cognition that develops over a short period of time and fluctuates. Possible causes of delirium are manifold: usually delirium is considered to develop in a multifactorial way, caused by inalterable parameters, such as advanced age and pre-existing cognitive impairment and precipitated by modifiable parameters, such as the use of certain drugs or substance withdrawal. Delirium is a serious condition with a pronounced impact on morbidity, mortality and costs to the healthcare system. Circumstances and drugs that might precipitate or worsen delirium should therefore be avoided whenever possible. A list of drugs that might have a detrimental influence on the emergence and duration of delirium has been created using the terms "delirogenity" and "delirogenic" to describe the potential of a drug or withdrawal to cause or worsen delirium. The results are novel and noteworthy, as their focus is on substances relevant to European pharmacotherapy. Furthermore, they represent a methodical consensus from a group of experts of a wide variety of professions relevant to the prevention, diagnosis and treatment of delirium, such as nursing, pharmacy, pharmacology, surgical and internal medicine, neurology, psychiatry, intensive care and medicine, with working, teaching and scientific experience in several European countries practicing both in primary and secondary care.

ESPEN guideline on nutrition and hydration in dementia - Update 2024.

BACKGROUND & AIMS: Dementia is accompanied by a variety of changes that result in an increased risk of malnutrition and low-intake dehydration. This guideline update aims to give evidence-based recommendations for nutritional care of persons with dementia in order to prevent and treat these syndromes. METHODS: The previous guideline version was reviewed and expanded in accordance with the standard operating procedure for ESPEN guidelines. Based on a systematic search in three databases, strength of evidence of appropriate literature was graded by use of the SIGN system. The original recommendations were reviewed and reformulated, and new recommendations were added, which all then underwent a consensus process. RESULTS: 40 recommendations for nutritional care of older persons with dementia were developed and agreed, seven at institutional level and 33 at individual level. As a prerequisite for good nutritional care, organizations caring for persons with dementia are recommended to employ sufficient qualified staff and offer attractive food and drinks with choice in a functional and appealing environment. Nutritional care should be based on a written care concept with standardized operating procedures. At the individual level, routine screening for malnutrition and dehydration, nutritional assessment and close monitoring are unquestionable. Oral nutrition may be supported by eliminating potential causes of malnutrition and dehydration, and adequate social and nursing support (including assistance, utensils, training and oral care). Oral nutritional supplements are recommended to improve nutritional status but not to correct cognitive impairment or prevent cognitive decline. Routine use of dementia-specific ONS, ketogenic diet, omega-3 fatty acid supplementation and appetite stimulating agents is not recommended. Enteral and parenteral nutrition and hydration are temporary options in patients with mild or moderate dementia, but not in severe dementia or in the terminal phase of life. In all stages of the disease, supporting food and drink intake and maintaining or improving nutrition and hydration status requires an individualized, comprehensive approach. Due to a lack of appropriate studies, most recommendations are good practice points. CONCLUSION: Nutritional care should be an integral part of dementia management. Numerous interventions are available that should be implemented in daily practice. Future high-quality studies are needed to clarify the evidence.

[Problems of pain measurement and pain therapy in the elderly]. / Problemfelder in der Schmerzmessung und Schmerztherapie im Alter.

Due to complex physical and psychological changes in aging, pain measurement and therapeutic treatment of older and geriatric patients present a special challenge. Nevertheless, even for this category of patients, good treatment results are achievable if age-related particulars and problems are consistently heeded and accounted for. That includes adverse sensory and cognitive effects as much as multimorbidity and the polypharmacy that is frequently related to it. An essential prerequisite for adequate pain therapeutic care in elderly patients is consistent pain measurement. While numerical and verbal scales have also proven their usefulness for patients in advanced age who are not cognitively impaired, instruments must be applied for older people with communicative and/or cognitive restrictions with which the observed behavior of those involved can be surveyed in a multidimensional way.

[Nutrition at the End of Life - Ethical Aspects]. / Ernährung am Lebensende ­ ethische Aspekte.

Nutritional problems at the end of life are of multifactorial origin, they require an interdisciplinary and multiprofessional approach. A basic precondition in deciding a nutritional therapeutic intervention is a valid medical indication. Fundamental ethical principles have to be respected.Another relevant question is if the nutritional therapeutic intervention will serve a meaningful, attainable goal in accordance with the patient's individual preferences and whether the expected benefit outweighs the potential risks. Particularly in older patients with a higher risk of cognitive impairment there is the question of the patient's ability to communicate his/her personal preferences, if he/she is able to give informed consent.Nutritional problems, particularly the refusal to eat can present a burdensome situation for the patient's carers. The potential reasons and causes for these problems have to be evaluated by an interdisciplinary assessment and medical differential diagnosis. This process has to involve the patient, his family and carers, ethical and palliative care counsel should be available.The topic of artificial feeding by means of a percutaneous gastrostomy - its relevance in the end of life situation, particularly in advanced stages of dementia is also addressed.

Optimizing medical care for geriatric patients in Austria: defining a top five list of "Choosing Wisely" recommendations using the Delphi technique.

PURPOSE: Inappropriate use of diagnostic and therapeutic medical procedures is common and potentially harmful for older patients. The Austrian Society of Geriatrics and Gerontology defined a consensus of five recommendations to avoid overuse of medical interventions and to improve care of geriatric patients. METHODS: From an initial pool of 147 reliable recommendations, 20 were chosen by a structured selection process for inclusion in a Delphi process to define a list of five top recommendations for geriatric medicine. 12 experts in the field of geriatric medicine scored the recommendations in two Delphi rounds. RESULTS: The final five recommendations are concerning urinary catheters in elderly patients, percutaneous feeding tubes in patients with advanced dementia, antipsychotics as the first choice to treat behavioral and psychological symptoms of dementia, and screening for breast, colorectal, prostate, or lung cancer, and the use of antimicrobials to treat asymptomatic bacteriuria. CONCLUSIONS: The selected recommendations have the potential to improve medical care for older patients, to reduce side effects caused by unnecessary medical procedures, and to save costs in the health care system.

ESPEN guidelines on nutrition in dementia.

BACKGROUND: Older people suffering from dementia are at increased risk of malnutrition due to various nutritional problems, and the question arises which interventions are effective in maintaining adequate nutritional intake and nutritional status in the course of the disease. It is of further interest whether supplementation of energy and/or specific nutrients is able to prevent further cognitive decline or even correct cognitive impairment, and in which situations artificial nutritional support is justified. OBJECTIVE: It is the purpose of these guidelines to cover these issues with evidence-based recommendations. METHODS: The guidelines were developed by an international multidisciplinary working group in accordance with officially accepted standards. The GRADE system was used for assigning strength of evidence. Recommendations were discussed, submitted to Delphi rounds and accepted in an online survey among ESPEN members. RESULTS: 26 recommendations for nutritional care of older persons with dementia are given. In every person with dementia, screening for malnutrition and close monitoring of body weight are recommended. In all stages of the disease, oral nutrition may be supported by provision of adequate, attractive food in a pleasant environment, by adequate nursing support and elimination of potential causes of malnutrition. Supplementation of single nutrients is not recommended unless there is a sign of deficiency. Oral nutritional supplements are recommended to improve nutritional status but not to correct cognitive impairment or prevent cognitive decline. Artificial nutrition is suggested in patients with mild or moderate dementia for a limited period of time to overcome a crisis situation with markedly insufficient oral intake, if low nutritional intake is predominantly caused by a potentially reversible condition, but not in patients with severe dementia or in the terminal phase of life. CONCLUSION: Nutritional care and support should be an integral part of dementia management. In all stages of the disease, the decision for or against nutritional interventions should be made on an individual basis after carefully balancing expected benefit and potential burden, taking the (assumed) patient will and general prognosis into account.

Prevalence and associations of potentially inappropriate prescriptions in Austrian nursing home residents: secondary analysis of a cross-sectional study.

BACKGROUND: Potentially inappropriate prescriptions (PIP) are an important cause of adverse medication-related events and increases morbidity, hospitalization, and health care costs, especially in nursing home residents. However, little is known about the associations between PIP and residents' characteristics. OBJECTIVE: The aim of our study was to analyse the prevalence and associations of PIP with residents' and facilities' characteristics. METHODS: We performed a secondary analysis of a cross-sectional study with 48 out of 50 eligible nursing homes and 1,844 out of 2,005 eligible residents in a defined rural-urban area in Austria. The Austrian list of potentially inappropriate medications was applied for the evaluation of inappropriate prescribing. Cluster-adjusted multiple regression analysis was used to investigate institutional and residents' characteristics associated with PIP. RESULTS: Mean cluster-adjusted prevalence of residents with at least one PIP was 70.3 % (95 % CI 67.2-73.4). The number of residents with at least one psychotropic PIP was 1.014 (55 %). The most often prescribed PIP were Prothipendyl (25.9 % residents), Lorazepam (14.5 %) and Diclofenac (6.1 %). Multiple regression analysis showed an inverse association of PIP with cognitive impairment and significant positive associations with permanent restlessness and permanent negative attitude. The associations of PIP with age and male gender were inconsistent. No significant associations were found for PIP and the ratio of staff nurses to residents. CONCLUSIONS: Our study results confirm that PIP is highly prevalent in the nursing home population. These results urgently call for effective interventions. Initiatives and successful interventions performed in other countries could serve as examples for safer prescribing in residents in Austria.

Potentially inappropriate medication in geriatric patients: the Austrian consensus panel list.

BACKGROUND: The practice of inappropriate medication and drug prescription is a major risk factor for adverse drug reactions in geriatric patients and increases the individual, as well as overall, rates of hospital admissions, resulting in increased health care expenditures. A consensus-based list of drugs, generally to be avoided in geriatric patients, is a practical tool to possibly improve the quality of prescribing. OBJECTIVE: The aim was to develop a consensus-based list of potentially inappropriate medications (PIM) for geriatric patients in Austria. Local market characteristics and documented prescribing regimens were considered in detail. METHODS: A two-round Delphi process involving eight experts in the field of geriatric medicine was undertaken to create a list of potentially inappropriate medications. Using a 5-point Likert scale (from strong agreement to strong disagreement), mean ratings from the experts were evaluated for each drug selected in the first round. The participants were first asked to comment on the potential inappropriateness of a preliminary list of drugs, and to propose alternate substances missing in the previous questionnaire for a second rating process. All drugs whose upper limit of the 95% CI was less than 3.0 were classified as potentially inappropriate. Drugs with a 95% CI enclosing 3.0 entered a second rating by the experts, in addition to other substances suggested during the first questionnaire. Drugs in the second rating were evaluated in comparable fashion to the first one. The final list was synthesized from the results in both rounds. RESULTS: Out of a preliminary list of 102 drugs, 61 drugs (59.2%) were classified as potentially inappropriate for geriatric persons in the first Delphi- round. In the second rating, six drugs that were reevaluated, and six drugs proposed additionally, were rated as potentially inappropriate. The final list contains 73 drugs to be avoided in older patients because of an unfavorable benefit/risk profile and/or unproven effectiveness. The list also contains suggestions for therapeutic alternatives and information about pharmacological and pharmacokinetic characteristics of all drugs judged as potentially inappropriate. CONCLUSION: The current Austrian list of potentially inappropriate medications may be a helpful tool for clinicians to increase the quality of prescribing in older patients. Like all explicit lists previously published, its validity needs to be proven in validation studies.

Soluble transferrin receptor and iron status in elderly patients.

The measurement of soluble transferrin receptor (sTfR) has been proposed as a novel approach to the diagnosis of iron deficiency, especially in anaemia of chronic diseases (ACD). Our aim was to study the utility of sTfR under 'everyday conditions' as seen in a geriatric hospital in the following groups of patients: First, in a pilot group of 99 multimorbid geriatric patients (85 women, 14 men; 82.00 +/- 6.32 years) admitted for rehabilitation after recent surgical treatment of a bone fracture; second, in 677 geriatric patients (506 women, 171 men; 79.17 +/- 11.47 years) with different diagnoses admitted to a department of internal medicine; third, in some remarkable clinical cases in order to illustrate the diagnostic limits of sTfR. In general, both genders showed a remarkable age-dependent decrease in erythropoiesis. In patients with haemoglobin levels below 12.0 mg/dL, this parameter correlated significantly with sTfR. However, this was seen only in women, not in men. Moreover, an age-dependent increase in sTfR was seen in women, while in men it remained almost constant. Based on these findings, we conclude that there is a different, gender-specific aetiology of iron deficiency in the elderly. About 30% of patients of both genders simultaneously had low haemoglobin levels and low sTfR. This was interpreted as 'adaptation' or 'tolerance' to the iron deficiency. This was illustrated by a clinical case of megaloblastic anaemia: Initially low sTfR rose only during the vitamin B12 substitution and normalized after recovery. We conclude that sTfR provides an insight into the 'dynamics' of iron metabolism: A rise in sTfR indicates an 'acute readiness to refill iron stores', while a low (non-stimulated) sTfR level corresponds to the quite frequent adaptation to iron deficiency and/or inhibition of resorption. Finally, extremely high sTfR levels were observed in some cases of malignancy such as in acute leukaemia and in hypernephroma. Thus, increased sTfR levels can be caused by paraneoplastic effects.