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Delirium is an acute neuropsychiatric syndrome and one of the most common presenting symptoms of acute medical illnesses in older people. Delirium can be triggered by a single cause, but in most cases, it is multifactorial as it depends on the interaction between predisposing and precipitating factors. Delirium is highly prevalent in older patients across various settings of care and correlates with an increased risk of adverse clinical outcomes. Several pathophysiological mechanisms may contribute to its onset, including neurotransmitter imbalance, neuroinflammation, altered brain metabolism, and impaired neuronal network connectivity. Several screening and diagnostic tools for delirium exist, but they are unfortunately underutilized. Additionally, the diagnosis of delirium superimposed on dementia poses a formidable challenge – especially if dementia is severe. Non-pharmacological approaches for the prevention and multidomain interventions for the treatment of delirium are recommended, given that there is currently no robust evidence of drugs that can prevent or resolve delirium. This article aims to review the current understanding about delirium in older people. To achieve this goal, we will describe the epidemiology and outcomes of the syndrome, the pathophysiological mechanisms that are supposed to be involved, the most commonly used tools for screening and diagnosis, and prevention strategies and treatments recommended. This review is intended as a brief guide for clinicians in hospital wards to improve their knowledge and practice. At the end of the article, we propose an approach to improve the quality of care provided to older patients throughout a systematic detection of delirium.

Key summary points Aim Delirium in patients with dementia (DSD) is highly frequent but often under-recognized and misdiagnosed as dementia. Findings This review discusses the current epidemiology of DSD, its pathogenesis, diagnosis and management. Message Delirium can be diagnosed in patients with dementia though its diagnosis is challenging, especially when dementia is severe. The multiprofessional approach is key to provide the best care to patients with DSD. Purpose Delirium superimposed on dementia (DSD) is a frequent and growing emerging clinical challenge, given the increasing prevalence of dementia. Methods This narrative review focuses on and discusses the current knowledge on epidemiology, pathogenesis, diagnosis and management of DSD. Results There is a close interaction between delirium and dementia since dementia is a risk factor for delirium and delirium is a known risk factor for newly developed dementia or worsening of dementia. The occurrence of DSD causes adverse clinical outcomes. However, DSD is often under-recognized or is frequently considered as the regular course of dementia. Indeed, especially in the advance stages of dementia, DSD diagnosis is challenging since a clear distinction between symptoms attributable to delirium and to dementia is difficult. Given the importance of DSD, it is essential to educate health care providers on the best approach for delirium management and treatment. It is now well recognized that delirium can be prevented using multicomponent interventions carried out by a multidisciplinary team targeting predisposing and precipitating risk factors for delirium. On the contrary, antipsychotics should only be used in patients with severe distressing symptoms and whose behavior means their safety or the safety of those around them is compromised, given the harmful of these medications in patients with pre-existing dementia. Conclusions It is essential to improve health care providers knowledge on DSD to improve the quality of care for an epidemiologically relevant though understudied population.

Background Respiratory failure due to COVID-19 pneumonia is associated with high mortality and may overwhelm health care systems, due to the surge of patients requiring advanced respiratory support. Shortage of intensive care unit (ICU) beds required many patients to be treated outside the ICU despite severe gas exchange impairment. Helmet is an effective interface to provide continuous positive airway pressure (CPAP) noninvasively. We report data about the usefulness of helmet CPAP during pandemic, either as treatment, a bridge to intubation or a rescue therapy for patients with care limitations (DNI). Methods In this observational study we collected data regarding patients failing standard oxygen therapy (i.e., non-rebreathing mask) due to COVID-19 pneumonia treated with a free flow helmet CPAP system. Patients’ data were recorded before, at initiation of CPAP treatment and once a day, thereafter. CPAP failure was defined as a composite outcome of intubation or death. Results A total of 306 patients were included; 42% were deemed as DNI. Helmet CPAP treatment was successful in 69% of the full treatment and 28% of the DNI patients ( P  < 0.001). With helmet CPAP, PaO 2 /FiO 2 ratio doubled from about 100 to 200 mmHg ( P  < 0.001); respiratory rate decreased from 28 [22–32] to 24 [20–29] breaths per minute, P  < 0.001). C-reactive protein, time to oxygen mask failure, age, PaO 2 /FiO 2 during CPAP, number of comorbidities were independently associated with CPAP failure. Helmet CPAP was maintained for 6 [3–9] days, almost continuously during the first two days. None of the full treatment patients died before intubation in the wards. Conclusions Helmet CPAP treatment is feasible for several days outside the ICU, despite persistent impairment in gas exchange. It was used, without escalating to intubation, in the majority of full treatment patients after standard oxygen therapy failed. DNI patients could benefit from helmet CPAP as rescue therapy to improve survival. Trial Registration : NCT04424992

The SARS-CoV-2 pandemic has led to a dramatic crisis of Health Care Systems worldwide, and older people have been among the most disadvantaged. Specific recommendations and reports have been released both at International and National level, regarding the diagnosis and management of COVID-19 in the elderly. However, little has been proposed for an appropriate response to older, frail and multimorbid patients in different settings of care (acute care units, long term care facilities, nursing homes and primary care) and for the management of geriatric syndromes (i.e. delirium, sarcopenia, falls). We presume that the current pandemic of will leads to substantial changes in health care systems, and we suggest some key guide principles that could inspire the provision of healthcare services to older people and their families. These principles are primarily directed to physicians and nurses working in the geriatric field but could also be useful for other specialists.

Frailty indices derived from electronic health records offer an efficient approach to identify vulnerable individuals in the general population. We aimed to validate the electronic-regional healthcare database frailty index (e-RHD-FI) in the general adult population, describe its distribution by sex and age, evaluate its predictive validity for mortality, hospitalization and fragility fractures, and assess the performance of frailty cut-off points. We conducted a population-based study of 8,404,004 adult beneficiaries of the Lombardy Regional Health System. The e-RHD-FI was calculated from 40 health deficits using electronic health records from 2008 to 2018. We assessed its distribution, predictive validity for 1-year mortality, hospitalizations and fragility fractures through multi-state analysis and multivariable models evaluating performance across subgroups. The e-RHD-FI distribution was highly asymmetrical (median 0.0125, first-third quartiles 0–0.0375), with 45.8% of adults having no deficits. The index was higher in older adults. Each 0.1-point increment in e-RHD-FI was associated with doubled 1-year mortality risk (HR 2.12, 99% CI 2.11–2.14), 2.5-fold increased hospitalization rate (IRR 2.51, 99% CI 2.49–2.53), and a 55% higher risk of fragility fracture (HR 1.55, 99% CI 1.53–1.57). The AUC for 1-year mortality was 0.883 (99% CI 0.881–0.884). The e-RHD-FI demonstrates strong predictive validity for adverse outcomes in the general population and can effectively identify at-risk individuals for targeted interventions.

Background New evidence is emerging on the importance of lean body mass during periods of illness and recovery. The preservation of lean body mass during such periods of intense stress impacts both patient and treatment outcomes. However, data concerning the incidence of sarcopenia among older people during hospitalization are scarce. The objective of this study was to evaluate the development of sarcopenia in a sample of hospitalized older subjects. Methods We used data of 394 participants from the multicentre Italian Study conducted by the Gruppo Lavoro Italiano Sarcopenia—Trattamento e Nutrizione (GLISTEN) in 12 Acute Care Wards (Internal Medicine and Geriatrics) of University Hospitals across Italy. This study was designed to determine the prevalence of sarcopenia at hospital admission and the change in muscle mass and strength during hospitalization. Sarcopenia was defined as low skeletal mass index (kg/m2) along with either low handgrip strength or slow walking speed [European Working Groups on Sarcopenia in Older People (EWGSOP) criteria]. Estimation of skeletal muscle mass was performed by bioelectrical impedance analysis (BIA). Results The mean age of the 394 enrolled patients (including 211 females who accounted for 53% of the sample) was 79.6 ± 6.4 years. Among those without sarcopenia at hospital admission, 14.7% of the study sample met the EWGSOP sarcopenia diagnostic criteria at discharge. The incidence of sarcopenia during hospitalization was significantly associated with the number of days spent in bed but was not correlated with the total length of hospital stay. In particular, patients who developed sarcopenia spent an average of 5.1 days in bed compared with 3.2 days for those with no sarcopenia at discharge (P = 0.02). Patients with sarcopenia showed a significantly lower body mass index compared with non‐sarcopenic peers (25.0 ± 3.8 kg/m2 vs. 27.6 ± 4.9 kg/m2, respectively; P < 0.001). Similarly, the skeletal mass index at admission was significantly lower among patients who developed sarcopenia during hospital stay. Conclusions Incident sarcopenia during hospital stay is relatively common and is associated with nutritional status and the number of days of bed rest.

BackgroundDelirium is associated with a variety of adverse healthcare outcomes but is highly predictable, preventable and treatable. For this reason, numerous guidelines have been developed for delirium recognition, prevention and management across different countries and disciplines. Although research is adduced as evidence for these guidelines, a constant finding is the lack of implementation if they exist at all. Implementation is a human behaviour that can be influenced by various factors including culture at a micro- and macro-level. Hofstede’s model proposes that national cultures vary along six consistent dimensions.AimUsing this model, we examined the nature of delirium guidelines across countries in relation to Hofstede’s six cultural dimensions.MethodsData collected for each country on: the six dimensions of Hofstede’s model, number of delirium guidelines approved by a National professional body of each country (through searching databases), the annual old-age dependency ratio for each country.ResultsSixty-four countries had the completed six dimensions of Hofstede’s model. Twenty of them (31%) had one or more delirium guidelines. The total number of different delirium guidelines was 45. Countries with formal delirium guidelines have significantly lower power distance among their members, are more individualistic societies, have lower levels of uncertainty avoidance and higher old-age dependency ratio compared to those without delirium guidelines.Discussion/conclusionThe development and implementation of delirium guidelines vary across countries. Specific combinations of cultural dimensions influence the production of delirium guidelines. Understanding these important cultural differences can facilitate more widespread acceptance and implementation of guidelines.

Aging is associated with an exaggerated response to peripheral inflammatory challenges together with behavioral and cognitive deficits. Studies considering both age and sex remain limited, despite sex dimorphism of astrocytes and microglial cells is largely recognized. To fill this knowledge gap, we investigated the effect of a single intraperitoneal lipopolysaccharide (LPS) administration in adult and aged mice. We assessed the expression of different inflammatory mediators, and the microglial response through binding of [18F]-VC701 tracer to translocator protein (TSPO) receptors in the male and female brain. Aged female brain showed a higher pro-inflammatory response to LPS compared to adult female and to aged male, as revealed by ex vivo binding to TSPO receptors and pro-inflammatory mediator transcript levels. The highest astroglial reaction was observed in the brain of aged females. Differently to the other groups of animals, in aged males LPS challenge did not affect transcription of triggering receptor expressed on myeloid cells 2 (TREM2). In conclusion, our study shows that in the mouse brain the neuroinflammatory response to an acute peripheral insult is sex and age dependent. Moreover, our results might set the basis for further studies aimed at identifying sex related targets involved in the modulation of the aberrant neuro-inflammatory response that characterizes aging. This knowledge could be relevant for the treatment of conditions such as delirium and dementia.