Considerations Regarding Management of Heart Failure in Older Adults

Understanding noncardiovascular comorbidities and geriatric syndromes in elderly patients with heart failure (HF) is important as the average age of the population increases. Healthcare professionals need to consider these complex dynamics when managing older adults with HF, especially those older than 80. A number of small studies have described associations between HF and major geriatric domains. With information on patients' cognitive, functional decline, and ability to adhere to therapy, physicians can plan for individualized treatment goals and recommendations for these patients.

Association between use of antihypertensives and cognitive decline in the elderly-A retrospective observational study

AIM

Mild cognitive impairment (MCI) is the prodromal phase of dementia. The objective of this study was to determine whether specific antihypertensives were associated with conversion from MCI to dementia.

METHODS

In this retrospective study, a chart review was conducted on 335 older adults seen at the University of Alberta Hospital, Kaye Edmonton Seniors Clinic who were diagnosed with MCI. At the point of diagnosis, data was collected on demographic and lifestyle characteristics, measures of cognitive function, blood pressure measurements, use of antihypertensives, and other known or suspected risk factors for cognitive decline. Patients were followed for 5.5 years for dementia diagnoses. A logistic regression analysis was then conducted to determine the factors associated with conversion from MCI to dementia.

RESULTS

Mean age (± standard deviation) of the study participants was 76.5 ± 7.3 years. Patients who converted from MCI to dementia were significantly older and were more likely to have a family history of dementia. After controlling for potential confounders including age, sex, Mini Mental Status Exam scores and family history of dementia, patients who were on beta-blockers (BBs) had a 57% reduction in the odds of converting to dementia (OR: 0.43, 95% CI: 0.23, 0.81).

CONCLUSIONS

In this study, BB use was protective against conversion from MCI to dementia. Further studies are required to confirm the findings of our study and to elucidate the effect of BBs on cognitive decline.

Predictors of Conversion to Dementia in Patients With Mild Cognitive Impairment: The Role of Low Body Temperature

Background

Subjects with mild cognitive impairment (MCI) can progress to dementia. Studies have shown that neuropsychological tests, biological or radiological markers individually or in combination have helped to determine the risk of conversion from MCI to dementia. These techniques are complex and expensive, and clinical risk factors were not considered in these studies. This study examined demographic, lifestyle and clinical factors including low body temperature that may play a role in the conversion of MCI to dementia in elderly patients.

Methods

In this retrospective study, a chart review was conducted on patients aged 61 to 103 years who were seen at the University of Alberta Hospital. Information on onset of MCI and demographic, social, and lifestyle factors, family history of dementia and clinical factors, and current medications at baseline was collected from patient charts on an electronic database. The conversion from MCI to dementia within 5.5 years was also determined. Logistic regression analysis was conducted to identify the baseline factors associated with conversion from MCI to dementia.

Results

The prevalence of MCI at baseline was 25.6% (335/1,330). During the 5.5 years follow-up period, 43% (143/335) of the subjects converted to dementia from MCI. The factors that were significantly associated with conversion from MCI to dementia were family history of dementia (odds ratio (OR): 2.78, 95% confidence interval (CI): 1.56 - 4.95, P = 0.001), Montreal cognitive assessment (MoCA) score (OR: 0.91, 95% CI: 0.85 - 0.97, P = 0.01), and low body temperature (below 36 °C) (OR: 10.01, 95% CI: 3.59 - 27.88, P < 0.001).

Conclusion

In addition to family history of dementia and MoCA, low body temperature was shown to be associated with the conversion from MCI to dementia. This study would help clinicians to identify patients with MCI who are at highest risk of conversion to dementia.

Abstract P223: Hypertension Telemonitoring And Protocolized Case Management For Community-Dwelling Older Adults: A Randomized Controlled Trial

Background: Home blood pressure (BP) telemonitoring combined with case management leads can reduce BP in adults with hypertension. However, the benefits of telemonitoring and case management for hypertension are not well established in older (age >= 65 years) adults. Interventions that can safely improve BP control in this distinct group will be critically important, particularly given recent trials showing cardiovascular benefits of intensive BP lowering in this group, and their increased vulnerability to over-treatment-related side effects.

Methods: Twelve-month, open-label, randomized controlled trial of community-dwelling older adults comparing home BP telemonitoring (HBPM) with pharmacist-led case management versus enhanced usual care with HBPM alone. The primary outcome was the proportion achieving age-specific systolic BP targets on 24-hour ambulatory BP monitoring (ABPM). Changes in HBPM were also examined. Logistic and linear regression were used for analyses, with adjustment for baseline BP.

Results: Subjects randomized to intervention (n = 61) and control (n = 59) groups were mostly female (77%), with mean age of 79.5 years. The adjusted odds ratio (aOR) for ABPM BP target achievement was 1.48 (95% CI 0.87-2.52, p = 0.15). At 12 months, the mean difference in BP changes between intervention and control groups was -1.6/-1.1 for ABPM (p-value 0.26 for systolic and 0.10 for diastolic BP), and -4.9/-3.1 for HBPM (p-value 0.04 for systolic BP and 0.01 for diastolic BP), favoring the intervention. Intervention group subjects had a higher rate of systolic BP < 110 (21% vs 5%, p = 0.009), but no differences in orthostatic symptoms, syncope, non-mechanical falls, or ED visits. Adherence to HBPM declined by 12 months, with 65% of trial-completers providing all 4 of the study-driven 3-monthly HBPM series.

Conclusions: Home BP telemonitoring and pharmacist case management did not improve achievement of target range ambulatory BP, but did reduce home BP. It was not associated with major adverse consequences. Further trials will be necessary to refine HBPM interventions, improve adherence, and determine effectiveness in older individuals more conclusively.

Microbial Therapeutics in Neurocognitive and Psychiatric Disorders

Microbial therapeutics, which include gut biotics and fecal transplantation, are interventions designed to improve the gut microbiome. Gut biotics can be considered as the administration of direct microbial populations. The delivery of this can be done through live microbial flora, certain food like fiber, microbial products (metabolites and elements) obtained through the fermentation of food products, or as genetically engineered substances, that may have therapeutic benefit on different health disorders. Dietary intervention and pharmacological supplements with gut biotics aim at correcting disruption of the gut microbiota by repopulating with beneficial microorganism leading to decrease in gut permeability, inflammation, and alteration in metabolic activities, through a variety of mechanisms of action. Our understanding of the pharmacokinetics of microbial therapeutics has improved with in vitro models, sampling techniques in the gut, and tools for the reliable identification of gut biotics. Evidence from human studies points out that prebiotics, probiotics and synbiotics have the potential for treating and preventing mental health disorders, whereas with paraprobiotics, proteobiotics and postbiotics, the research is limited at this point. Some animal studies point out that gut biotics can be used with conventional treatments for a synergistic effect on mental health disorders. If future research shows that there is a possibility of synergistic effect of psychotropic medications with gut biotics, then a gut biotic or nutritional prescription can be given along with psychotropics. Even though the overall safety of gut biotics seems to be good, caution is needed to watch for any known and unknown side effects as well as the need for risk benefit analysis with certain vulnerable populations. Future research is needed before wide spread use of natural and genetically engineered gut biotics. Regulatory framework for gut biotics needs to be optimized. Holistic understanding of gut dysbiosis, along with life style factors, by health care providers is necessary for the better management of these conditions. In conclusion, microbial therapeutics are a new psychotherapeutic approach which offer some hope in certain conditions like dementia and depression. Future of microbial therapeutics will be driven by well-done randomized controlled trials and longitudinal research, as well as by replication studies in human subjects.

Holistic perspective of the role of gut microbes in diabetes mellitus and its management

The gut microbiota (GM) plays a role in the development and progression of type 1 and type 2 diabetes mellitus (DM) and its complications. Gut dysbiosis contributes to the pathogenesis of DM. The GM has been shown to influence the efficacy of different antidiabetic medications. Intake of gut biotics, like prebiotics, probiotics and synbiotics, can improve the glucose control as well as the metabolic profile associated with DM. There is some preliminary evidence that it might even help with the cardiovascular, ophthalmic, nervous, and renal complications of DM and even contribute to the prevention of DM. More large-scale research studies are needed before wide spread use of gut biotics in clinical practice as an adjuvant therapy to the current management of DM.

Income disparity and incident cardiovascular disease in older Americans

OBJECTIVE

To examine the association between income and cardiovascular disease (CVD) in community-dwelling older adults.

METHODS

Of the 5795 Medicare-eligible community-dwelling older Americans aged 65-100 years in the Cardiovascular Health Study (CHS), 4518 (78%) were free of baseline CVD, defined as heart failure, acute myocardial infarction, stroke, or peripheral arterial disease. Of them, 1846 (41%) had lower income, defined as a total annual household income <$16,000. Using propensity scores for lower income, estimated for each of the 4518 participants, we assembled a matched cohort of 1078 pairs balanced on 42 baseline characteristics. Outcomes included centrally adjudicated incident CVD and mortality.

RESULTS

Matched participants (n = 2156) had a mean age of 73 years, 63% were women, and 13% African American. During an overall follow-up of 23 years, incident CVD, all-cause mortality and the combined endpoint of incident CVD or mortality occurred in 1094 (51%), 1726 (80%) and 1867 (87%) individuals, respectively. Compared with the higher income group, hazard ratio (HR) for time to the first occurrence of incident CVD in the lower income group was 1.16 with a 95% confidence interval of 1.03 to 1.31. A lower income was also associated with a significantly higher risk of all-cause mortality (HR, 1.19; 95% CI, 1.08-1.30), and consequently a higher risk of the combined endpoint of incident CVD or death (HR, 1.20; 95% CI, 1.09-1.31).

CONCLUSION

Among community-dwelling older Americans free of baseline CVD, an annual household income <$16,000 is independently associated with significantly higher risks of new-onset CVD and death.

Gut microbes in neurocognitive and mental health disorders

INTRODUCTION

As individuals age, the prevalence of neurocognitive and mental health disorders increases. Current biomedical treatments do not completely address the management of these conditions. Despite new pharmacological therapy the challenges of managing these diseases remain.There is increasing evidence that the Gut Microbiome (GM) and microbial dysbiosis contribute to some of the more prevalent mental health and neurocognitive disorders, such as depression, anxiety, obsessive-compulsive disorder (OCD), post-traumatic stress disorder (PTSD), schizophrenia, bipolar disorder (BP), and dementia as well as the behavioural and psychological symptoms of dementia (BPSD) through the microbiota-gut-brain axis. Methodology: Scoping review about the effect of gut microbiota on neurocognitive and mental health disorders.

RESULTS

This scoping review found there is an evolving evidence of the involvement of the gut microbiota in the pathophysiology of neurocognitive and mental health disorders. This manuscript also discusses how the psychotropics used to treat these conditions may have an antimicrobial effect on GM, and the potential for new strategies of management with probiotics and faecal transplantation.

CONCLUSIONS

This understanding can open up the need for a gut related approach in these disorders as well as unlock the door for the role of gut related microbiota management. KEY MESSAGES Challenges of managing mental health conditions remain in spite of new pharmacological therapy. Gut dysbiosis is seen in various mental health conditions. Various psychotropic medications can have an influence on the gut microbiota by their antimicrobial effect.

Impact of frailty on outcomes after discharge in older surgical patients: a prospective cohort study

BACKGROUND

Frailty is a state of vulnerability to diverse stressors. We assessed the impact of frailty on outcomes after discharge in older surgical patients.

METHODS

We prospectively followed patients 65 years of age or older who underwent emergency abdominal surgery at either of 2 tertiary care centres and who needed assistance with fewer than 3 activities of daily living. Preadmission frailty was defined according to the Canadian Study of Health and Aging Clinical Frailty Scale as "well" (score 1 or 2), "vulnerable" (score 3 or 4) or "frail" (score 5 or 6). We assessed composite end points of 30-day and 6-month all-cause readmission or death by multivariable logistic regression.

RESULTS

Of 308 patients (median age 75 [range 65-94] yr, median Clinical Frailty Score 3 [range 1-6]), 168 (54.5%) were classified as vulnerable and 68 (22.1%) as frail. Ten (4.2%) of those classified as vulnerable or frail received a geriatric consultation. At 30 days after discharge, the proportions of patients who were readmitted or had died were greater among vulnerable patients (n = 27 [16.1%]; adjusted odds ratio [OR] 4.60, 95% confidence interval [CI] 1.29-16.45) and frail patients (n = 12 [17.6%]; adjusted OR 4.51, 95% CI 1.13-17.94) than among patients who were well (n = 3 [4.2%]). By 6 months, the degree of frailty independently and dose-dependently predicted readmission or death: 56 (33.3%) of the vulnerable patients (adjusted OR 2.15, 95% CI 1.01-4.55) and 37 (54.4%) of the frail patients (adjusted OR 3.27, 95% CI 1.32-8.12) were readmitted or had died, compared with 11 (15.3%) of the patients who were well.

INTERPRETATION

Vulnerability and frailty were prevalent in older patients undergoing surgery and unlikely to trigger specialized geriatric assessment, yet remained independently associated with greater risk of readmission for as long as 6 months after discharge. Therefore, the degree of frailty has important prognostic value for readmission.

TRIAL REGISTRATION FOR PRIMARY STUDY

ClinicalTrials.gov, no. NCT02233153.

Utilization of computerized clinical decision support for potentially inappropriate medications

Background: Electronic medical record (EMR) alerts may inform point of care decisions, including the decision to prescribe potentially inappropriate medications (PIM) identified in the Beers criteria. EMR alerts may not be considered relevant or informative in the clinician context, leading to a phenomenon colloquially known as “alert fatigue.”

Objective: To assess the frequency of clinical interaction with EMR alerts and associated deprescribing behaviors in ambulatory settings.

Methods: This is a retrospective observational study in two ambulatory clinics (the Kaye Edmonton Clinic Senior’s Clinic and the Lynnwood Family Practice Clinic) in Edmonton over an observational period of 30 months. Statistical analysis was done using descriptive statistics, chi-square and regression analysis.

Results: The reminder performance for interactions with the alert was 17.2% across the two clinics. The Number Needed to Remind (NNR) or mean number of alerts shown on clinician screens prior to a single interaction of any kind with the alert was 5.8. When actions were defined as a deprescribing (ie discontinuation) event that was related to the alert and that particular interaction in the EMR, the reminder performance was 1.2%, for an NNR of 82.8.

Conclusion: The configuration of alerts in the EMR was not associated with a clinically detectable increase in the uptake of the Beers criteria for high hazard medications.

Classic challenges and emerging approaches to medication therapy in older adults

Prescribing medications safely and effectively in older adults is a complex process. This review discusses challenges with medication prescribing in older adults and outlines a holistic approach to medication management in older adults. Well-known challenges including the alterations in pharmacokinetics and pharmacodynamics that often occur with aging are discussed. Other classic concerns including polypharmacy, potentially inappropriate medication use, prescribing cascades, suboptimal prescribing, paradoxical harm and unintended consequences of medications, and drug interactions are reviewed. Newer approaches, including deprescribing, pharmacogenomics, and the future potential for senolytic therapy are also discussed. All healthcare providers should consider these challenges when prescribing medications in older adults. Choosing a drug that fits both a patient's pathophysiology and biology, avoiding drugs with significant side effects, titrating doses, and deprescribing are all critical in optimizing medication therapy.

Role of Geriatric Syndromes in the Management of Atrial Fibrillation in Older Adults: A Narrative Review

OBJECTIVES

Atrial fibrillation (AF) is common in older adults and associated with increased risk of cardiovascular events including thromboembolism. However, less is known about its association with noncardiovascular events, especially geriatric syndromes and conditions such as dementia, depression, impaired physical function, polypharmacy, falls, and poor quality of life. This review aims to help healthcare professionals integrate the special needs of older adults into their management of AF.

DESIGN

Nonsystematic review. A literature search on published articles on AF and geriatric syndromes and conditions was performed using the electronic databases MEDLINE, EMBASE and SCOPUS, and DARE until December 2017. Non-English articles were excluded.

SETTINGS AND PARTICIPANTS

Older adults with and without AF from different settings.

MEASURES

Various cognitive, mood, and functional measurements were used in these studies. In studies regarding polypharmacy, the Beers or PRISCUS criteria were used to identify inappropriate medications. In quality of life measurements studies, instruments like Medical Outcomes Study Short Form 36 and Atrial Fibrillation Quality of Life questionnaire were used.

RESULTS

This literature review finds that AF has a substantial association with geriatric syndromes and conditions and that AF is a risk factor for the development of geriatric syndromes and conditions. Evidence is limited regarding the potential benefit of long-term treatment of AF in lowering the risk of developing geriatric syndromes and conditions.

CONCLUSIONS/IMPLICATIONS

Considering the impact of AF on cardiovascular outcomes and geriatric syndromes and conditions in older adults, healthcare professionals need to consider these complex dynamics while managing AF in older adults. An individual approach to AF management is needed in older adults with multiple comorbidity and polypharmacy that may help lower the risk of disease-disease, disease-drug, and drug-drug interactions. Special consideration needs to be given to patients' cognitive and functional impairment and ability to adhere to therapy.

Cardiac rehabilitation and its effects on cognition in patients with coronary artery disease and heart failure

INTRODUCTION

Cardiac rehabilitation program is an evidence-based intervention and established model of exercise delivery following myocardial infarction and heart failure. Although it forms an important part of recovery and helps to prevent future events and complications, there has been little focus on its potential cognitive benefits. Areas covered: Coronary artery disease and heart failure are common heart problems associated with significant morbidity and mortality, and cognitive decline is commonly seen in affected individuals. Cognitive impairment may influence patient self-management by reducing medication adherence, rendering patients unable to make lifestyle modifications and causing missed healthcare visits. Cognitive assessment in cardiac rehabilitation as an outcome measure has the potential to improve clinical, functional and behavioral domains as well as help to reduce gaps in the quality of care in these patients. Expert commentary: Limited evidence at present has shown that cardiac rehabilitation and exercise has potential in preventing cognitive decline. Cardiac prehabilitation, a rehabilitation-like program delivered before cardiac surgery, may also play a role in preventing postoperative cognitive dysfunction, but needs future research studies to support it.

Comparison of the Assessment of Orthostatic Hypotension Using Peripheral and Central Blood Pressure Measurements

BACKGROUND

Orthostatic hypotension (OH) is associated with falls and cardiovascular events. There is growing evidence that central blood pressure (CBP) is better than peripheral blood pressure (PBP) in predicting adverse outcomes. The objectives of this study were to assess 1) the prevalence of OH identified using PBP and CBP and the levels of agreement, 2) the respective associations between OH and falls and cardiovascular comorbidities, by PBP and CBP, and 3) the association of OH with arterial wall stiffness markers (augmentation pressure (AP) and augmentation index (AI)).

METHODS

An observational case-control study of subjects aged 50 years and above was conducted at the University of Alberta Hospital inpatient wards and outpatient clinics. This study used a non-invasive technology called SphygmoCor to assess changes in CBP between lying, 1, 3 and 6 min of standing. AP and AI, which are markers of arterial wall stiffness, were also measured in this study. Dementia, significant psychological problems, and isolation precautions were exclusion criteria. Both PBP and CBP were measured with arm cuffs in lying and standing positions. OH was diagnosed using consensus criteria.

RESULTS

Of the 71 participants recruited, mean age was 72.3 ±10.3 years, 52% were males, 32% had a history of falls and 72% had hypertension. OH occurred within 1, 3 or 6 min of standing (transient OH) in 31% by PBP and 27% by CBP (kappa = 0.56). OH persisted for all 6 min (persistent OH) in 16% by both PBP and CBP (kappa = 0.68). A significant relationship was observed between transient OH by CBP and baseline hypertension (P = 0.05) and dyslipidemia (P = 0.02). There was a significant difference in the mean AP between subjects with and without central persistent OH (P = 0.02), but not between subjects with and without peripheral persistent OH. The mean AI was not significantly different between subjects with or without central or peripheral persistent OH and between subjects with and without peripheral or central transient OH.

CONCLUSION

Prevalence of OH was similar between PBP and CBP. However, there was only moderate agreement with OH identified by PBP and CBP indicating some inconsistencies across the sample in identifying OH.

Association between central blood pressure, arterial stiffness, and mild cognitive impairment

Background

To determine the relationship between central blood pressure (CBP) indices and mild cognitive impairment (MCI) in adults over the age of 50.

Methods

A cross-sectional study conducted using a non-invasive SphygmoCor XCEL device. CBP indices and brachial blood pressure were measured in 50 inpatients and outpatients. MCI was assessed using the Montreal Cognitive Assessment (MoCA) instrument and by the European Consortium Criteria (ECC).

Results

Seventy-six percent of subjects had hypertension, and 52% were diagnosed as having MCI using the ECC. No significant association was found between any of the measured blood pressure variables and global cognition. A significant relationship was observed between augmentation index (AI) and abnormal clock-drawing (p = 0.04) and language (p = 0.02), and between pulse pressure amplification (PPA) and language (p = 0.03).

Conclusion

CBP indices like AI and PPA, which are markers of vascular stiffness, are associated with poor executive function and language cognitive domain deficits.

Complex relationship of obesity and obesity paradox in heart failure - higher risk of developing heart failure and better outcomes in established heart failure

Heart failure (HF) and obesity are major public health problems. Studies have shown that obesity may increase the risk of developing new HF but after patients have developed HF, obesity may be associated with improved outcomes. This paradoxical association of obesity with HF remains poorly understood. It is believed that the obesity paradox may in part be due to the inherent limitations of body mass index (BMI) as a measure of obesity. BMI may not appropriately measure important components of body mass like body fat, fat distribution, lean body mass, and body fluid content and may not be ideal for examining the relationship of body composition with health outcomes. Differentiating between body fat and lean body mass may explain some of the paradoxical association between higher BMI and better prognosis in patients with HF. Paradoxical outcomes in HF may also be due to phenotypes of obesity. Future studies need to develop and test metrics that may better measure body composition and may serve as a better tool for the estimation of the true association of obesity and outcomes in HF and determine whether the association may vary by obesity phenotypes. KEY MESSAGES Obesity predisposes to heart failure in all age groups. But obesity in heart failure is an area of controversy, because of obesity paradox, the apparent protective effect of overweight and mild obesity on mortality after development of heart failure. Traditional markers of obesity do not measure different components of body weight like muscle mass, fat, water, and skeletal weight. Body Mass Index in heart failure subjects does not measure accurately body fat or fluid retention. So new markers of obesity like visceral adiposity index, body composition analysis, sarcopenic status assessment may be helpful in the assessment of heart failure outcomes. Different phenotypes of obesity may be responsible for the different morbidity, mortality as well as therapeutic outcomes in heart failure.

Telemonitoring and Protocolized Case Management for Hypertensive Community-Dwelling Seniors With Diabetes: Protocol of the TECHNOMED Randomized Controlled Trial

Background

Diabetes and hypertension are devastating, deadly, and costly conditions that are very common in seniors. Controlling hypertension in seniors with diabetes dramatically reduces hypertension-related complications. However, blood pressure (BP) must be lowered carefully because seniors are also susceptible to low BP and attendant harms. Achieving “optimal BP control” (ie, avoiding both undertreatment and overtreatment) is the ultimate therapeutic goal in such patients. Regular BP monitoring is required to achieve this goal. BP monitoring at home is cheap, convenient, widely used, and guideline endorsed. However, major barriers prevent proper use. These may be overcome through use of BP telemonitoring—the secure teletransmission of BP readings to a health portal, where BP data are summarized for provider and patient use, with or without protocolized case management.

Objective

To examine the incremental effectiveness, safety, cost-effectiveness, usability, and acceptability of home BP telemonitoring, used with or without protocolized case management, compared with “enhanced usual care” in community-dwelling seniors with diabetes and hypertension.

Methods

A 300-patient, 3-arm, pragmatic randomized controlled trial with blinded outcome ascertainment will be performed in seniors with diabetes and hypertension living independently in seniors’ residences in greater Edmonton. Consenting patients will be randomized to usual care, home BP telemonitoring alone, or home BP telemonitoring plus protocolized pharmacist case management. Usual care subjects will receive a home BP monitor but neither they nor their providers will have access to teletransmitted data. In both telemonitored arms, providers will receive telemonitored BP data summaries. In the case management arm, pharmacist case managers will be responsible for reviewing teletransmitted data and initiating guideline-concordant and protocolized changes in BP management.

Results

Outcomes will be ascertained at 6 and 12 months. Within-study-arm change scores will be calculated and compared between study arms. These include: (1) clinical outcomes: proportion of subjects with a mean 24-hour ambulatory systolic BP in the optimal range (110-129 mmHg in patients 65-79 years and 110-139 mmHg in those ≥80 years: primary outcome); additional ambulatory and home BP outcomes; A1c and lipid profile; medications, cognition, health care use, cardiovascular events, and mortality. (2) Safety outcomes: number of serious episodes of hypotension, syncope, falls, and electrolyte disturbances (requiring third party assistance or medical attention). (3) Humanistic outcomes: quality of life, satisfaction, and medication adherence. (4) Economic outcomes: incremental costs, incremental cost-utility, and cost per mmHg change in BP of telemonitoring ± case management compared with usual care (health payor and societal perspectives). (5) Intervention usability and acceptability to patients and providers.

Conclusion

The potential benefits of telemonitoring remain largely unstudied and unproven in seniors. This trial will comprehensively assess the impact of home BP telemonitoring across a range of outcomes. Results will inform the value of implementing home-based telemonitoring within supportive living residences in Canada.

Trial Registration

Clinicaltrials.gov NCT02721667; https://clinicaltrials.gov/ct2/show/NCT02721667 (Archived by Webcite at http://www.webcitation.org/6i8tB20Mc)

An investigation of videoconferenced geriatric medicine grand rounds in Alberta

Geriatric medicine grand rounds (GMGR) from the University of Alberta are videoconferenced weekly to health-care providers at up to 9 urban and 14 rural sites across Alberta. A questionnaire was given to all participants attending 20 consecutive GMGR presentations from January 2002. The response rate was 85% ( n = 625) for all participants and 99% ( n = 123) for physicians alone. The audience was composed of registered nurses (42%), physicians (17%) and other health-care professionals. 'Interest in topic' was cited by 95% as the main reason for attendance. Doctors and nurses cited continuing medical education as an additional factor. The highest attendance was for the topics vascular dementia, behavioural problems in dementia, the genetics of dementia and falls prevention. Participants at the remote sites gave lower evaluations of quality of the GMGR presentations than those at the hub site. The measurement, care and treatment of dementia appeared to be the main concerns of health-care providers across the province. The videoconferencing of GMGR appears to be an effective method of meeting the demands of physicians and allied health professionals for education in geriatric medicine.

Melatonin based therapies for delirium and dementia

Melatonin levels have been shown to decline with aging. Melatonin and its analogs in addition to their effect on sleep promotion, has been shown to have multiple pleiotropic effects. It can also help with neuroprotection through different mechanisms. Evidence in animal and human studies suggests that low levels of melatonin have been linked to delirium, mild cognitive impairment, dementia, and with certain behavioral problems. Recent clinical trials have showed that both melatonin and its analogs may be useful in the prevention, treatment of delirium, and the management of dementia. These medications seem to have the advantage of less side effects and better safety profile when compared to antipsychotics and sedatives like benzodiazepines. These medications are available over the counter in North America, Europe, and Asia, and some of these medications are approved by FDA. This manuscript will discuss the promising role of these melatonergic medications alone or in combination with other medications for the management of Geriatric Psychiatric diseases like delirium and dementia.

Resting and Post-Exercise Ankle-Brachial Index Measurements to Diagnose Asymptomatic Peripheral Arterial Disease in Middle Aged and Elderly Chronic Obstructive Pulmonary Disease Patients: A Pilot Study

BACKGROUND

Chronic obstructive pulmonary disease (COPD) patients are at risk for asymptomatic peripheral arterial disease (PAD) because smoking is a risk factor for COPD and PAD. The objectives of this study were to determine the proportion of COPD patients with asymptomatic PAD and to investigate whether the estimated risk of asymptomatic PAD in subjects with COPD differs using resting and exercise ankle-brachial index (ABI) in smokers.

METHODS

Using a cross-sectional study design, consecutive smokers > 50 years old were recruited over 2 months from the inpatient units and the outpatient clinics. Subjects previously diagnosed with PAD, unstable angina, recent (< 3 months) myocardial infarction or abdominal, intracranial, eye or lung surgery, and palliative care patients were excluded. Vascular risk factors, ABI (supine and post-3-minute walk supine), self-reported PAD symptoms, and spirometry were obtained. Two measurements of systolic blood pressure on all limbs were obtained using a sphygmomanometer and a Doppler ultrasound, and the ABI was calculated. Data were expressed as means ± standard deviation (SD). Dichotomous outcomes were assessed using Chi-square statistics; P-values of < 0.05 were considered significant.

RESULTS

Thirty patients with no previous diagnosis of PAD were recruited. Mean age was 67.7 years (SD: 10.5). Overall, 21 subjects (70%) had spirometry-proven COPD. Significant ABI for PAD (< 0.9) was seen in 7/21 COPD (33.5%) and 0/9 non-COPD subjects in the supine resting position (P = 0.07), and in 9/21 COPD (42.9%) vs. 0/9 non-COPD subjects after exercise (P = 0.03).

CONCLUSIONS

A significant proportion of patients with spirometry-proven COPD screened positive for asymptomatic PAD after exercise. Resting ABI may not be very sensitive to diagnose asymptomatic PAD in COPD subjects. ABI may be a reliable, sensitive and practical screening tool to assess cardiovascular risk in COPD patients. Future large-scale studies are required to confirm this finding.

Physicians' use of computerized clinical decision supports to improve medication management in the elderly - the Seniors Medication Alert and Review Technology intervention

Background

Elderly people (aged 65 years or more) are at increased risk of polypharmacy (five or more medications), inappropriate medication use, and associated increased health care costs. The use of clinical decision support (CDS) within an electronic medical record (EMR) could improve medication safety.

Methods

Participatory action research methods were applied to preproduction design and development and postproduction optimization of an EMR-embedded CDS implementation of the Beers’ Criteria for medication management and the Cockcroft–Gault formula for estimating glomerular filtration rates (GFR). The “Seniors Medication Alert and Review Technologies” (SMART) intervention was used in primary care and geriatrics specialty clinics. Passive (chart messages) and active (order-entry alerts) prompts exposed potentially inappropriate medications, decreased GFR, and the possible need for medication adjustments. Physician reactions were assessed using surveys, EMR simulations, focus groups, and semi-structured interviews. EMR audit data were used to identify eligible patient encounters, the frequency of CDS events, how alerts were managed, and when evidence links were followed.

Results

Analysis of subjective data revealed that most clinicians agreed that CDS appeared at appropriate times during patient care. Although managing alerts incurred a modest time burden, most also agreed that workflow was not disrupted. Prevalent concerns related to clinician accountability and potential liability. Approximately 36% of eligible encounters triggered at least one SMART alert, with GFR alert, and most frequent medication warnings were with hypnotics and anticholinergics. Approximately 25% of alerts were overridden and ~15% elicited an evidence check.

Conclusion

While most SMART alerts validated clinician choices, they were received as valuable reminders for evidence-informed care and education. Data from this study may aid other attempts to implement Beers’ Criteria in ambulatory care EMRs.

Association between vitamin D and respiratory outcomes in Canadian adolescents and adults

BACKGROUND

Asthma is one of the most prevalent chronic diseases worldwide, affecting more than 200 million people. Vitamin D deficiency has been reported among individuals with asthma and might play a role in asthma exacerbations. In this cross-sectional study, we investigated the association of serum 25-hydroxy vitamin D [25(OH)D] levels and current asthma, ever asthma, and lung function.

METHODS

Data from 3937 subjects aged 13-69 years who participated in the Canadian Health Measures Survey - Cycle 1 were considered in this study. Serum 25(OH)D levels were categorized into ≤49 nmol/L (low), 50-74 nmol/L (moderate) and ≥75 nmol/L (high).

RESULTS

The proportion of subjects with current and ever asthma was greater in the lower 25(OH)D category than in moderate and high categories. After adjusting for potential confounders, subjects in the low 25(OH)D levels were more likely to have current asthma than those in the moderate levels (OR: 1.54, 95% CI: 1.01-2.36). Low 25(OH)D levels were also associated with ever asthma (OR: 2.12, 95% CI: 1.40-3.21) among those with a family history of asthma and this association was stronger in those with asthma onset before 20 years of age. High 25(OH)D levels were associated with lower mean value of FEV1/FVC ratio. No significant association was observed between 25(OH)D levels and other lung function measurements.

CONCLUSION

In this study, 25(OH)D levels below 50 nmol/L were associated with an increased risk of current and ever asthma. Further exploration of this relationship is needed to determine the optimal level of vitamin D in the management of asthma in adolescents and adults.

Small vessel disease/white matter disease of the brain and its association with osteoporosis

BACKGROUND

Evidence now suggests the role of neural effect on bone mass control. The effect of small vessel disease of the brain on osteoporosis has not been studied. The aim of this study was to investigate the association of white matter disease (WMD) of the brain with osteoporosis in the elderly.

METHODS

In this retrospective cross-sectional study, 780 consecutive patient charts between 2010 and 2011 were reviewed in the Senior's Outpatient Clinic at the University of Alberta Hospital. Subjects with brain computerized tomography (CT) were included in the study. Subjects with incomplete information, intracranial hemorrhage, acute stroke, cerebral edema, and/or normal pressure hydrocephalus on the CT were excluded. WMD was quantified on CT using Wahlund's scoring protocol. Osteoporosis information was obtained from the chart, which has been diagnosed based on bone mineral density (BMD) information. Logistic regression analysis was done to determine the association of WMD severity with osteoporosis after controlling for confounding vascular risk factors.

RESULTS

Of the 505 subjects who were included in the study, 188 (37%) had osteoporosis and 171 (91%) of these osteoporotic subjects were females. The mean age was 79.8 ± 7.04 years. The prevalence of WMD in osteoporosis subjects was 73%. In the unadjusted logistic regression analysis, there was a significant association between WMD severity and osteoporosis (odds ratio (OR): 1.10; 95% confidence interval (CI): 1.05 - 1.14; P < 0.001) and the significance remained in the adjusted model, after correcting for age, sex and all vascular risk factors (OR: 1.11; 95% CI: 1.05 - 1.18; P < 0.001).

CONCLUSION

WMD severity of the brain was associated with osteoporosis in the elderly.

White matter disease severity of the brain and its association with geriatric syndromes

BACKGROUND AND AIM

White matter disease (WMD) of the brain is considered to be secondary to small vessel ischemia and can be a single unifying risk factor for the development of geriatric syndromes. The aim of our study was to investigate the association of the global and regional severity of WMD in the brain with geriatric syndromes burden.

METHODS

In our retrospective study, consecutive outpatient charts from patients seen between January 2010 and June 2011 at University of Alberta Hospital Seniors Clinic were reviewed. Subjects with brain computed tomography (CT) scans were included in the study. Subjects with incomplete information or with diseases that confounded WMD assessment on CT were excluded. White matter disease was quantified on CT using Wahlund scoring. A multiple linear regression analysis was conducted to determine the association of WMD severity with geriatric syndromes burden after controlling for confounding vascular risk factors.

RESULTS

Of the 505 subjects, 326 (64.6%) were women. Mean age of the study patients was 79.8 years (SD ± 7.04), prevalence of WMD disease was 79.4%, and mean WMD score was 5.1 (SD ± 4.4). In subjects aged < and > 80 years, the mean number of geriatric syndromes was 2.83 (standard error of the mean [SE] 0.08) and 3.22 (SE 0.08), respectively. In the adjusted regression analysis, there was a significant association between WMD severity, globally (regression coefficient (β) = 0.457, SE 0.155; P = 0.003), as well as WMD in specific regions: frontal (P < 0.001), parieto-occipital (P = 0.004), and infratentorial regions (P = 0.04) with geriatric syndromes burden. The association remains even after correcting for age, sex, and all vascular risk factors.

CONCLUSION

In our study, there was a significant association between the severity of global and selected regional WMD of the brain with geriatric syndromes burden, thus raising the possibility of a shared biologic association through vascular pathology of the brain.

Antidiabetic drugs and their potential role in treating mild cognitive impairment and Alzheimer's disease

The incidence of both diabetes mellitus (DM) and dementia increases with aging and the incidence of dementia are higher in people with diabetes. Epidemiological and pathological data suggest that DM contributes to mild cognitive impairment (MCI) and dementia. DM seems to be an independent risk factor for MCI and Alzheimer's disease (AD) and is associated with more rapid cognitive decline. Recent evidence points out that insulin affects central nervous system functions, and can modulate cognitive functions. Impaired insulin signaling and insulin resistance in brain have been found to play an important role in the pathogenesis of AD. Human studies have shown that some oral antidiabetic medications can improve cognition in patients with MCI and AD. Intranasal insulin has also been shown to improve memory and cognitive abilities in MCI and AD patients. While it remains unclear whether management of diabetes will reduce the incidence of MCI and AD, emerging evidence suggests that diabetes therapies may improve cognitive function.

Orthostatic hypotension and incident heart failure in community-dwelling older adults

OBJECTIVES

To examine the association of orthostatic hypotension with incident heart failure (HF) in older adults.

METHODS

Of the 5,273 community-dwelling adults aged 65 years and older free of baseline prevalent HF in the Cardiovascular Health Study, 937 (18%) had orthostatic hypotension, defined as ≥20 mmHg drop in systolic or ≥10 mmHg drop in diastolic blood pressure from supine to standing position at 3 minutes. Of the 937, 184 (20%) had symptoms of dizziness upon standing and were considered to have symptomatic orthostatic hypotension. Propensity scores for orthostatic hypotension were estimated for each of the 5,273 participants and were used to assemble a cohort of 3,510 participants (883 participants with and 2,627 participants without orthostatic hypotension) who were balanced on 40 baseline characteristics. Cox regression models were used to estimate the association of orthostatic hypotension with centrally adjudicated incident HF and other outcomes during 13 years of follow-up.

RESULTS

Participants (n = 3,510) had a mean (±standard deviation) age of 74 (±6) years, 58% were women, and 15% nonwhite. Incident HF occurred in 25% and 21% of matched participants with and without orthostatic hypotension, respectively (hazard ratio, 1.24; 95% confidence interval, 1.06-1.45; p = .007). Among matched participants, hazard ratios for incident HF associated with symptomatic (n = 173) and asymptomatic (n = 710) orthostatic hypotension were 1.57 (95% confidence interval, 1.16-2.11; p = .003) and 1.17 (95% confidence interval, 0.99-1.39; p = .069), respectively.

CONCLUSIONS

Community-dwelling older adults with orthostatic hypotension have higher independent risk of developing new-onset HF, which appeared to be more pronounced in those with symptomatic orthostatic hypotension.

Update on diastolic heart failure or heart failure with preserved ejection fraction in the older adults

Nearly half of all heart failure (HF) patients have diastolic HF (DHF) or clinical HF with normal or near-normal left ventricular ejection fraction (LVEF). Although the terminology has not been clearly defined, it is increasingly being referred to as HF with preserved ejection fraction (HFPEF). The prevalence of HFPEF increases with age, especially among older women. Identifying HFPEF is important because the etiology, pathogenesis, prognosis, and optimal management may differ from that for systolic HF (SHF) or HF with reduced ejection fraction. The clinical presentation of HF is similar for both SHF and HFPEF. As in SHF, HFPEF is a clinical diagnosis. Once a clinical diagnosis of HF has been made, the presence of HFPEF can be established by confirming a normal or near-normal LVEF, often by an echocardiogram. HFPEF is often associated with a history of hypertension, concentric left ventricular hypertrophy, vascular stiffness, and left ventricular diastolic dysfunction. As in SHF, HFPEF is also associated with poor outcomes. While therapies with angiotensin-converting enzyme inhibitors and beta-blockers improve outcomes in SHF, there is currently no such evidence of their benefits in older HFPEF patients. In this review recent advances in the diagnosis and management of HFPEF in older adults are discussed.

Genetics and epigenetics of Alzheimer's disease

Alzheimer's disease (AD) is a highly prevalent condition that predominantly affects older adults. AD is a complex multifactorial disorder with a number of genetic, epigenetic and environmental factors which ultimately lead to premature neuronal death. Predictive and susceptibility genes play a role in AD. Early-onset familial AD is a rare autosomal dominant disorder. Genome-wide association studies have identified many potential susceptibility genes for late-onset AD, but the clinical relevance of many of these susceptibility genes is unclear. The genetic variation by susceptibility genes plays a crucial role in determining the risk of late-onset AD, as well as the onset of the disease, the course of the AD and the therapeutic response of patients to conventional drugs for AD. The newer understanding of the epigenetics in AD has also been highlighted. Recent advances in genetics, epigenetics and pharmacogenetics of AD pose new challenges to the future management of AD.

Impairment of activities of daily living and incident heart failure in community-dwelling older adults

AIMS

Instrumental activities of daily living (IADLs) are tasks that are necessary for independent community living. These tasks often require intact physical and cognitive function, the impairment of which may adversely affect health in older adults. In the current study, we examined the association between IADL impairment and incident heart failure (HF) in community-dwelling older adults.

METHODS AND RESULTS

Of the 5795 community-dwelling adults, aged ≥65 years, in the Cardiovascular Health Study, 5511 had data on baseline IADL and were free of prevalent HF. Of these, 1333 (24%) had baseline IADL impairment, defined as self-reported difficulty with one or more of the following tasks: using the telephone, preparing food, performing light and heavy housework, managing finances, and shopping. Propensity scores for IADL impairment, estimated for each of the 5511 participants, were used to assemble a cohort of 1038 pairs of participants with and without IADL impairment who were balanced on 42 baseline characteristics. Centrally adjudicated incident HF occurred in 26% and 21% of matched participants with and without IADL impairment, respectively, during >12 years of follow-up [matched hazard ratio (HR) 1.33; 95% confidence interval (CI) 1.11-1.59; P = 0.002]. Unadjusted and multivariable-adjusted HRs for incident HF before matching were 1.77 (95% CI 1.56-2.01; P < 0.001) and 1.33 (95% CI 1.15-1.54; P < 0.001), respectively. IADL impairment was also associated with all-cause mortality (matched HR 1.19; 95% CI 1.06-1.34; P = 0.004).

CONCLUSION

Among community-dwelling older adults free of baseline HF, IADL impairment is a strong and independent predictor of incident HF and mortality.

Silent acute gastric dilatation due to Salmonella infection in a diabetic elderly

Acute gastric dilatation is a potentially life-threatening entity that has been reported in patients with some acute infections like pneumonia and staphylococcal bacteremia. We describe a case of acute gastric dilatation presenting atypically in a 65-year-old diabetic with Salmonella diarrhoea. By the fourth day of hospital admission the patient's abdomen was distended in the absence of pain, nausea or vomiting. An abdominal radiograph showed marked gastric dilatation with no evidence of obstruction or ileus. With nasogastric tube insertion and initiation of intravenous antibiotics, the stomach was back to normal size. It is likely that Salmonella infection was the major cause of acute gastric dilatation in this patient.

Approach to managing hypoglycemia in elderly patients with diabetes

Hypoglycemia is a common clinical problem in elderly patients with diabetes. Aging modifies the counterregulatory and symptomatic responses to hypoglycemia. Hypoglycemia in the elderly is not only due to tight blood sugar control, but also due to a multitude of other factors. Hypoglycemia often occurs with insulin, sulfonylureas, or meglitinide therapy. However, other causes may also contribute to hypoglycemia, such as decreased cognition, renal impairment, or polypharmacy. The presenting features of hypoglycemia may be atypical and misinterpreted, resulting in delayed treatment. Morbidity is greater in elderly patients, and the risk of progression to severe hypoglycemia is high because of their altered symptom profile, diminished symptom intensity, and altered glycemic thresholds. Hypoglycemia seems to be the main limiting factor in their glycemic control. In this article we discuss strategies to prevent hypoglycemic episodes.

Gaps in patient care practices to prevent hospital-acquired delirium

OBJECTIVE

To evaluate the current patient care practices that address the predisposing and precipitating factors contributing to the prevention of hospital-acquired delirium in the elderly.

DESIGN

Prospective cohort (observational) study.

PARTICIPANTS

Patients 65 years of age and older who were admitted to medical teaching units at the University of Alberta Hospital in Edmonton over a period of 7 months and who were at risk of delirium.

SETTING

Medical teaching units at the University of Alberta.

MAIN OUTCOME MEASURES

Demographic data and information on predisposing factors for hospital-acquired delirium were obtained for all patients. Documented clinical practices that likely prevent common precipitants of delirium were also recorded.

RESULTS

Of the 132 patients enrolled, 20 (15.2%) developed hospital-acquired delirium. At the time of admission several predisposing factors were not documented (eg, possible cognitive impairment 16 [12%], visual impairment 52 [39.4%], and functional status of activities of daily living 99 [75.0%]). Recorded precipitating factors included catheter use, screening for dehydration, and medications. Catheters were used in 35 (26.5%) patients, and fluid intake-and-output charting assessed dehydration in 57 (43.2%) patients. At the time of admission there was no documentation of hearing status in 69 (52.3%) patients and aspiration risk in 104 (78.8%) patients. After admission, reorientation measures were documented in only 16 (12.1%) patients. Although all patients had brief mental status evaluations performed once daily, this was not noted to occur twice daily (which would provide important information about fluctuation of mental status) and there was no formal attention span testing. In this study, hospital-acquired delirium was also associated with increased mortality (P < .004), increased length of stay (P < .007), and increased institutionalization (P < .027).

CONCLUSION

Gaps were noted in patient care practices that might contribute to hospital-acquired delirium and also in measures to identify the development of delirium at an earlier stage. Effort should be made to educate health professionals to identify the predisposing and precipitating factors, and to screen for delirium. This might improve the prevention of delirium.

Patient acceptance of intranasal cobalamin gel for vitamin B12 replacement therapy

PURPOSE

Determine acceptance of and compliance with intranasal cobalamin (vitamin B12) replacement therapy.

METHODS

Veteran subjects were recruited from VA Outpatient facilities in Hawai'i. Information was obtained by interview and medical record review. Subjects received the standard dose of intranasal cobalamin of 500 micrograms intranasally, once a week. A follow-up questionnaire was administered at one and three months of therapy

RESULTS

Thirty-four subjects were enrolled in the study Ages ranged from 29 to 87 years of age, with a mean age of 68.6. Ninety-seven percent were men, 59% were Caucasian, and 35% were Asian/Pacific Islanders. At the end of three months, 30 patients had completed the study. Ninety percent preferred the gel over injection. In the subset of subjects with a history of depression, only 60% preferred intranasal gel.

CONCLUSION

Veteran patients tolerated intranasal cobalamin gel well. The majority of patients preferred intranasal over intramuscular injection of vitamin B12.

Treating vascular risk factors and maintaining vascular health: is this the way towards successful cognitive ageing and preventing cognitive decline?

Dementia is a progressive disorder that typically worsens with time and from which recovery is unlikely. The incidence of dementia increases exponentially with ageing and is an important public health challenge. There is now growing evidence for the role of vascular factors in Alzheimer's disease, mixed dementia (Alzheimer's disease with cerebrovascular disease), and of course vascular dementia. With the rising prevalence of vascular disease, there are increasing numbers of people who are identified to be at risk of cognitive impairment. By changing modifiable vascular risk factors, there is emerging evidence that it may be possible to prevent or delay the expression and progression of dementia.

Sexually inappropriate behaviour in demented elderly people

AIM

To determine the prevalence, aetiology, and treatment profile of abnormal sexual behaviour in subjects with dementia in psychogeriatric practices.

METHODS

A retrospective cross sectional study was conducted in a long term care psychiatry consultation service, community based geriatric psychiatry service, and an inpatient dementia behavioural unit in Edmonton, Canada.

RESULTS

Forty one subjects (1.8%) had sexually inappropriate behaviour. Of those cognitively impaired subjects with sexually inappropriate behaviour, 20 (48.8%) were living in nursing homes and the rest, 21 (51.2%) in the community. Of these subjects, 53.7% had vascular dementia, 22% had Alzheimer's, and 9.8% had mild cognitive impairment. History of alcohol misuse and psychosis were reported in 14.6% and 9.8% of subjects respectively. Twenty seven (65.7%) had verbally inappropriate behaviour and 36 (87.8%) had physically inappropriate behaviour. In this study, verbally inappropriate behaviour was more commonly seen in the community sample (81%) than in the nursing home sample (50%) (p = 0.04). Behavioural treatment was also more commonly seen in the community sample (81%) than in the nursing home sample (45%) (p = 0.01).

CONCLUSION

In this study sexually inappropriate behaviour was seen in all stages of dementia, more commonly associated with subjects of vascular aetiology, and is as commonly seen in community dwelling subjects with dementia as in nursing home subjects.

Relation of T-axis abnormalities to coronary artery disease and survival after cardiac catheterization

We investigated the association of an abnormal T axis with angiographic indicators of coronary artery disease and mortality. In univariate analysis, no significant association was observed between an abnormal T axis and extent of coronary artery disease (p = 0.928). An abnormal T axis was a significant predictor of overall mortality (p = 0.035) for death at any time in our unadjusted survival analysis, and a trend toward poorer survival persisted after adjustment for clinical covariates.

An approach to drug induced delirium in the elderly

Drugs have been associated with the development of delirium in the elderly. Successful treatment of delirium depends on identifying the reversible contributing factors, and drugs are the most common reversible cause of delirium. Anticholinergic medications, benzodiazepines, and narcotics in high doses are common causes of drug induced delirium. This article provides an approach for clinicians to prevent, recognise, and manage drug induced delirium. It also reviews the mechanisms for this condition, especially the neurotransmitter imbalances involving acetylcholine, dopamine, and gamma aminobutyric acid and discusses the age related changes that may contribute to altered pharmacological effects which have a role in delirium. Specific interventions for high risk elderly with the goal of preventing drug induced delirium are discussed.