Antibiotics for delirium in older adults with pyuria or bacteriuria: A systematic review.

BACKGROUND: It is unclear whether antibiotics impact delirium outcomes in older adults with pyuria or bacteriuria in the absence of systemic signs of infection or genitourinary symptoms. METHODS: We registered our systematic review protocol with PROSPERO (CRD42023418091). We searched the Medline and Embase databases from inception until April 2023 for studies investigating the impact of antimicrobial treatment on the duration and severity of delirium in older adults (≥60 years) with pyuria (white blood cells detected on urinalysis or dipstick) or bacteriuria (bacteria growing on urine culture) and without systemic signs of infection (temperature > 37.9C [>100.2F] or 1.5C [2.4F] increase above baseline temperature, and/or hemodynamic instability) or genitourinary symptoms (acute dysuria or new/worsening urinary symptoms). Two reviewers independently screened search results, abstracted data, and appraised the risk of bias. Full-text randomized controlled trials (RCTs) and observational study designs were included without restriction on study language, duration, or year of publication. RESULTS: We screened 984 citations and included 4 studies comprising 652 older adults (mean age was 84.6 years and 63.5% were women). The four studies were published between 1996 and 2022, and included one RCT, two prospective observational cohort studies, and one retrospective chart review. None of the four studies demonstrated a significant effect of antibiotics on delirium outcomes, with two studies reported a worsening of outcomes among adults who received antibiotics. The three observational studies included had a moderate or serious overall risk of bias, while the one RCT had a high overall risk of bias. CONCLUSIONS: Our systematic review found no evidence that treatment with antibiotics is associated with improved delirium outcomes in older adults with pyuria or bacteriuria and without systemic signs of infection or genitourinary symptoms. Overall, the evidence was limited, largely observational, and had substantial risk of bias.

Cholinesterase inhibitors and falls, syncope and injuries in patients with cognitive impairment: a systematic review and meta-analysis.

BACKGROUND: Cholinesterase inhibitors are commonly used to treat patients with neurocognitive disorders, who often have an elevated risk of falling. Effective use of these medications requires a thoughtful assessment of risks and benefits. OBJECTIVE: To provide an update on previous reviews and determine the association between cholinesterase inhibitors and falls, syncope, fracture and accidental injuries in patients with neurocognitive disorders. METHODS: Embase, MEDLINE, Cochrane Central Register of Controlled Trials, Cumulative Index of Nursing and Allied Health Literature and AgeLine were systematically searched through March 2023 to identify all randomised controlled trials of cholinesterase inhibitors (donepezil, galantamine, rivastigmine) in patients with cognitive impairment. Corresponding authors were contacted for additional data necessary for meta-analysis. Inclusion criteria consisted of adults ≥19 years, with a diagnosis of dementia, Parkinson's disease, mild cognitive impairment or traumatic brain injury. Data were extracted in duplicate for the aforementioned primary outcomes and all outcomes were analysed using random-effects meta-analysis. RESULTS: Fifty three studies (30 donepezil, 14 galantamine, 9 rivastigmine) were included providing data on 25, 399 patients. Cholinesterase inhibitors, compared to placebo, were associated with reduced risk of falls (risk ratio [RR] 0.84 [95% confidence interval [CI] = 0.73-0.96, P = 0.009]) and increased risk of syncope (RR 1.50 [95% CI = 1.02-2.21, P = 0.04]). There was no association with accidental injuries or fractures. CONCLUSION: In patients with neurocognitive disorders, cholinesterase inhibitors were associated with decreased risk of falls, increased risk of syncope and no association with accidental trauma or fractures. These findings will help clinicians better evaluate risks and benefits of cholinesterase inhibitors.

Associations Between Patient Characteristics and Unplanned or Delayed Discharges From Geriatric Rehabilitation: A Retrospective Chart Review.

ABSTRACT: Returning home is considered an indicator of successful rehabilitation for community-dwelling older adults. However, the factors associated with unplanned discharge remain uncertain. This retrospective chart review included patients 65 yrs and older admitted to a geriatric rehabilitation unit from medical and surgical wards in an academic hospital. Patient characteristics and outcomes were abstracted from the electronic medical record. The primary outcome was unplanned discharge destination defined as anything other than return to patients' preexisting residence. The associations between patient variables and unplanned discharge destination were analyzed using Pearson χ 2 and univariate logistic regression. Of the 251 charts screened, 25 patients (10.0%) had an unplanned discharge destination, and 74 of the remaining 226 (32.7%) experienced a delayed discharge (beyond 20 days). Requiring assistance for activities of daily living (odds ratio [OR], 2.80; 95% confidence interval [CI], 1.17-7.47), a diagnosis of chronic obstructive pulmonary disease (OR, 4.04; 95% CI, 1.63-9.71), and lower serum albumin level (OR, 1.67; 95% CI, 1.06-2.72) were associated with unplanned discharge. Variables commonly associated with worse outcomes such as age, cognitive scores, delirium, and number of comorbidities were not barriers to returning home and should therefore not be used on their own to limit access to geriatric rehabilitation.

Trends in Delirium and New Antipsychotic and Benzodiazepine Use Among Hospitalized Older Adults Before and After the Onset of the COVID-19 Pandemic.

Importance: The COVID-19 pandemic caused large disruptions to health care for hospitalized older adults. The incidence and management of delirium may have been affected by high rates of COVID-19 infection, staffing shortages, overwhelmed hospital capacity, and changes to visitor policies. Objective: To measure changes in rates of delirium and related medication prescribing during the COVID-19 pandemic among hospitalized older adults. Design, Setting, and Participants: This population-based, repeated cross-sectional study used linked databases to measure rates of delirium and related medication prescriptions among adults aged 66 years or older hospitalized before and during the COVID-19 pandemic (January 1, 2017, to March 31, 2022) in Ontario, Canada. Exposure: The first 2 years of the COVID-19 pandemic (March 1, 2020, to March 31, 2022). Main Outcomes and Measures: The main outcomes were weekly rates of delirium per 1000 admitted population and monthly rates of new antipsychotic and benzodiazepine prescriptions per 1000 discharged population. Observed rates were compared with projected rates based on modeling from 3 years before pandemic onset. Results: Among 2 128 411 hospitalizations of older adults over the 5-year study period (50.7% female; mean [SD] age, 78.9 [8.3] years), absolute rates of delirium increased from 35.9 per 1000 admitted population during the prepandemic period to 41.5 per 1000 admitted population throughout the pandemic. The adjusted rate ratio (ARR) of delirium during the pandemic compared with the projected rate was 1.15 (95% CI, 1.11-1.19). Monthly rates of new antipsychotic prescriptions increased from 6.9 to 8.8 per 1000 discharged population and new benzodiazepine prescriptions from 4.4 to 6.0 per 1000 discharged population and were significantly higher during the pandemic compared with projected rates (antipsychotics: ARR, 1.28; 95% CI, 1.19-1.38; benzodiazepines: ARR, 1.37; 95% CI, 1.20-1.57). Rates were highest during pandemic waves 1 (March to June 2020), 3 (March to June 2021), and 5 (December 2021 to February 2022) and remained elevated above projected levels throughout the first 2 years of the pandemic. Conclusions and Relevance: In this repeated cross-sectional study of hospitalized older adults, there was a temporal association between COVID-19 pandemic onset and significant increases in rates of delirium in the hospital and new antipsychotic and benzodiazepine prescriptions after hospital discharge. Rates remained elevated over 2 years. Pandemic-related changes such as visitor restrictions, staff shortages, isolation practices, and reduced staff time at the bedside may have contributed to these trends.

Predictors of persistent depressive and anxiety symptoms among older adults during the COVID-19 pandemic in Canada.

BACKGROUND: The COVID-19 pandemic has increased the risk of psychological distress for older adults during a period of reduced access to mental health support. We identified predictors of persistent depressive and anxiety symptoms among older adults throughout the initial 9 months of the pandemic. METHODS: This was a longitudinal study using web-based surveys sent to a convenience sample of Canadians aged ≥55 years. A baseline survey was sent in May 2020, with eight surveys sent monthly between June 2020 and January 2021. Data were separated into three study periods, corresponding to coronavirus case rates. Respondents who met predetermined thresholds for elevated depressive or anxiety symptoms using standardized mental health scales during all three periods were defined as having persistent symptoms. Multivariable Poisson regression was used to compare the risk of persistent symptoms across respondent characteristics selected a priori. RESULTS: There were 835 respondents who answered questions about depressive symptoms and 865 who answered questions about anxiety symptoms across all three study periods. Among those with complete follow-up data, 19.2% (n = 159/827) reported persistent depressive symptoms and 16.4% (n = 140/856) reported persistent anxiety symptoms. Respondents with persistent depressive symptoms were more likely to be women (adjusted relative risk [aRR] 1.71; 95% CI 1.19-2.46), and report multimorbidity (aRR 1.45; 95% CI 1.07-1.97), pre-existing depression (aRR 2.00; 95% CI 1.45-2.77) and pre-existing anxiety (aRR 1.50; 95% CI 1.10-2.06). The same respondent characteristics were correlates of persistently elevated anxiety symptoms. CONCLUSIONS: Older women, older adults with pre-existing depression and anxiety, and those with multimorbidity were more likely to report persistent mental health symptoms during the first 9 months of the COVID-19 pandemic. These individuals were known to have elevated risk prior to the pandemic, and expanded interventions targeted to these groups are necessary to adequately address their mental health needs.

Are Antibiotics Helpful for Older Adults with Delirium and Pyuria or Bacteriuria?

Antibiotics for Delirium and Pyuria or BacteriuriaDelirium is common among hospitalized older adults, frequently leading to initiation of antibiotics when pyuria or bacteriuria is detected. However, it is difficult to determine if pyuria or bacteriuria is the cause of delirium or incidentally identified. This article proposes a trial to assess if treatment with antibiotics hastens delirium resolution.

Sleep monitoring challenges in patients with neurocognitive disorders: A cross-sectional analysis of missing data from activity trackers.

Background and Aims: Activity monitors, such as Fitbits®, are being used increasingly for research purposes and data have been validated in healthy community-dwelling older adults. Given the lack of research in older adults with neurocognitive disorders, we investigated the consistency of sleep data recorded from a wrist-worn activity monitor in this population. Methods: Fitbit® activity monitors were worn by hospitalized older adults as part of a parent study investigating sleep and step count in patients recovering from hip fracture surgery in a tertiary care academic hospital in Hamilton, Canada between March 2018 and June 2019. In this secondary analysis, we compared the proportion of missing sleep data between participants with and without a neurocognitive disorder and used a multivariable model to assess the association between neurocognitive disorder and missing sleep data. Results: Of 67 participants included in the analysis, 22 had a neurocognitive disorder (median age: 86.5 years). Sleep data were missing for 47% of the neurocognitive disorder group and 23% of the non-neurocognitive disorder group. The presence of a neurocognitive disorder was associated with an increased likelihood of missing sleep data using the Fitbit® activity monitors (adjusted odds ratio: 3.41; 95% confidence interval: 1.06-11.73, p = 0.04). Conclusion: The inconsistent nature of sleep data tracking in hospitalized older adults with neurocognitive disorders highlights the challenges of using interventions in patient populations who are often excluded from validation studies. As opportunities expand for activity monitoring in persons with neurocognitive disorders, novel technologies not previously studied in this group should be used with caution.

Gender Differences in Mental Health Symptoms Among Canadian Older Adults During the COVID-19 Pandemic: a Cross-Sectional Survey.

Background: Older women's mental health may be disproportionally affected by the COVID-19 pandemic due to differences in gender roles and living circumstances associating with aging. Methods: We administered an online cross-sectional nationwide survey between May 1st and June 30th, 2020 to a convenience sample of older adults aged ≥55 years. Our outcomes were symptoms of depression, anxiety, and loneliness measured by three standardized scales: the eight-item Center for Epidemiological Studies Depression Scale, the five-item Beck Anxiety Inventory, and the Three-Item Loneliness Scale. Multivariable logistic regression was used to compare the odds of depression, anxiety and loneliness between men and women, adjusting for relevant confounders. Results: There were 1,541 respondents (67.8% women, mean age 69.3 ± 7.8). 23.3% reported symptoms of depression (29.4% women, 17.0% men), 23.2% reported symptoms of anxiety (26.0% women, 19.0% men), and 28.0% were lonely (31.5% women, 20.9% men). After adjustment for confounders, the odds of reporting depressive symptoms were 2.07 times higher in women compared to men (OR 2.07 [95%CI 1.50-2.87] p < .0001). The odds of reporting anxiety and loneliness were also higher. Conclusions: Older women had twice the odds of reporting depressive symptoms compared to men, an important mental health need that should be considered as the COVID-19 pandemic unfolds.

A Survey of Nurses' Perspectives on Delirium Screening in Older Adult Medical Inpatients With Limited English Proficiency.

The Confusion Assessment Method (CAM) is commonly used to detect delirium but its utility in patients with limited English proficiency (LEP) is not well-established. In the current study, internal medicine nurses at an acute care hospital in Canada were surveyed on the use of the CAM in older adults with LEP. Nurses' perspectives were explored with a focus on barriers to administration. Fifty participants were enrolled (response rate = 47.6%). Twenty-eight (56%) participants stated they could not confidently and accurately assess delirium in patients with LEP. Twenty-nine (58%) participants believed the CAM is not an effective delirium screening tool in the LEP population. Barriers to screening included: challenges with interpretation services, dependence on family members, and fear that the assessment itself may worsen confusion. Our study is the first to describe specific barriers to administering the CAM in patients with LEP. Strategies are required to address these barriers and optimize delirium screening for patients with LEP. [Journal of Gerontological Nursing, 47(4), 29-34.].

Loneliness among older adults in the community during COVID-19: a cross-sectional survey in Canada.

OBJECTIVE: Physical distancing and stay-at-home measures implemented to slow transmission of novel coronavirus disease (COVID-19) may intensify feelings of loneliness in older adults, especially those living alone. Our aim was to characterise the extent of loneliness during the first wave in a sample of older adults living in the community and assess characteristics associated with loneliness. DESIGN: Online cross-sectional survey between 6 May and 19 May 2020. SETTING: Ontario, Canada. PARTICIPANTS: Convenience sample of members of a national retired educators' organisation. PRIMARY OUTCOME MEASURES: Self-reported loneliness, including differences between women and men. RESULTS: 4879 respondents (71.0% women; 67.4% 65-79 years) reported that in the preceding week, 43.1% felt lonely at least some of the time, including 8.3% who felt lonely always or often. Women had increased odds of loneliness compared with men, whether living alone (adjusted OR (aOR) 1.52, 95% CI 1.13 to 2.04) or with others (2.44, 95% CI 2.04 to 2.92). Increasing age group decreased the odds of loneliness (aOR 0.69 (95% CI 0.59 to 0.81) 65-79 years and 0.50 (95% CI 0.39 to 0.65) 80+ years compared with <65 years). Living alone was associated with loneliness, with a greater association in men (aOR 4.26, 95% CI 3.15 to 5.76) than women (aOR 2.65, 95% CI 2.26 to 3.11). Other factors associated with loneliness included: fair or poor health (aOR 1.93, 95% CI 1.54 to 2.41), being a caregiver (aOR 1.18, 95% CI 1.02 to 1.37), receiving care (aOR 1.47, 95% CI 1.19 to 1.81), high concern for the pandemic (aOR 1.55, 95% CI 1.31 to 1.84), not experiencing positive effects of pandemic distancing measures (aOR 1.94, 95% CI 1.62 to 2.32) and changes to daily routine (aOR 2.81, 95% CI 1.96 to 4.03). CONCLUSIONS: While many older adults reported feeling lonely during COVID-19, several characteristics-such as being female and living alone-increased the odds of loneliness. These characteristics may help identify priorities for targeting interventions to reduce loneliness.

Worries, attitudes, and mental health of older adults during the COVID-19 pandemic: Canadian and U.S. perspectives.

BACKGROUND/OBJECTIVES: Differences in older adults' worry, attitudes, and mental health between high-income countries with diverging pandemic responses are largely unknown. We compared COVID-19 worry, attitudes towards governmental responses, and self-reported mental health symptoms among adults aged ≥55 in the United States and Canada early in the COVID-19 pandemic. DESIGN: Online cross-sectional survey administered between April 2nd and May 31st in the United States and between May 1st and June 30th, 2020 in Canada. SETTING: Nationally in the United States and Canada. PARTICIPANTS: Convenience sample of older adults aged ≥55. MEASUREMENTS: Likert-type scales measured COVID-19 worry and attitudes towards government support. Three standardized scales assessed mental health symptoms: the eight-item Center for Epidemiological Studies Depression Scale, the five-item Beck Anxiety Inventory, and the three-item UCLA loneliness scale. RESULTS: There were 4453 U.S. respondents (71.7% women; mean age 67.5) and 1549 Canadian (67.6% women; mean age 69.3). More U.S. respondents (71%) were moderately or extremely worried about the pandemic, compared to 52% in Canada. Just 20% of U.S. respondents agreed or strongly agreed that the federal government cared about older adults in their COVID-19 pandemic response, compared to nearly two-thirds of Canadians (63%). U.S. respondents were more likely to report elevated depressive and anxiety symptoms compared to Canadians; 34.2% (32.8-35.6) versus 25.6% (23.3-27.8) for depressive and 30.8% (29.5-32.2) versus 23.7% (21.6-25.9) for anxiety symptoms. The proportion of United States and Canadian respondents who reported loneliness was similar. A greater proportion of women compared to men reported symptoms of depression and anxiety across all age groups in both countries. CONCLUSION: U.S. older adults felt less supported by their federal government and had elevated depressive and anxiety symptoms compared to older adults in Canada during early months of the COVID-19 pandemic. Public health messaging from governments should be clear, consistent, and incorporate support for mental health.

Implementation of a multicomponent intervention sign to reduce delirium in orthopaedic inpatients (MIND-ORIENT): a quality improvement project.

Delirium is a serious and common condition that leads to significant adverse health outcomes for hospitalised older adults. It occurs in 30%-55% of patients with hip fractures and is one of the most common postoperative complications in older adults undergoing orthopaedic surgery. Multicomponent, non-pharmacological interventions can reduce delirium incidence by up to 30% but are often challenging to implement as part of routine care. We identified a gap in the delivery of non-pharmacological interventions on an orthopaedic unit. This project aimed to implement a bedside sign on an orthopaedic unit to reduce the occurrence of delirium by prompting staff to use multicomponent evidence-based delirium prevention strategies for at-risk older adults. Quality improvement methods were used to integrate and optimise the use of a bedside 'delirium prevention' sign on an orthopaedic unit.The sign was implemented in four target rooms and sign completion rates increased from 47% to 83% (95% CI 71.7% to 94.9%; p<0.001) over a 10-month period. The sign did not have a significant impact on delirium prevalence. The mean Confusion Assessment Method (CAM)+ rate during the baseline period was 8% with an absolute increase in the intervention period to 11.4% (95% CI 7.2% to 15.8%; p=0.31). There were no significant shifts or trends in the run chart for the proportion of patients with CAM+ scores over time. The sign was well received by staff, who reported it was a worthwhile use of time and prompted use of non-pharmacological interventions. This quality improvement project successfully integrated a novel, low-cost, feasible and evidence-based approach into routine clinical care to support staff to deliver non-pharmacological interventions. Given the increased pressures on front-line staff in hospital, tools that reduce cognitive load at the bedside are important to consider when caring for a vulnerable older adult patient population.