Seniors

Detecting delirium in elderly patients

Delirium is an acute confusional state that, in elderly people, is associated with increased mortality and long hospital stays. It can often be reversed by treatment of the underlying cause; however, the delirium must first be identified. Researchers performed a cross-sectional study and chart review to determine the prevalence and detection rates of delirium among elderly patients seen in the emergency department. Overall, 10% of the patients were found to have delirium, as diagnosed by a research psychiatrist using the Confusion Assessment Method; in only 35% of cases was delirium diagnosed in the emergency department using chart review or a mental status checklist. The authors conclude that despite the relatively high prevalence of delirium among elderly emergency department patients, the current methods of detection are insufficient. CMAJ 2000;163(8):977-81.

Osteoporosis: Catching a time bomb among the elderly

Osteoporosis produces no symptoms and the disease is very difficult to detect before a fracture occurs. However, once that first fracture does occur treatment remains especially important and valuable since the rate of clinically serious fractures of the hip and spine increases as much as 20-fold after the first fragility fracture. Researchers surveyed 228 patients who had presented to Ontario fracture clinics with fractures associated with bone fragility. The authors sought to determine whether the patients had received investigation and treatment of osteoporosis. Of the 108 eligible patients who responded, only 20 (18.5%) had received a diagnosis of osteoporosis either before or within one year of the fracture and 43 (39.8%) had experienced previous fractures. Of the 20 who received a diagnosis of osteoporosis, eight (40%) were taking hormone replacement therapy and eight (40%) were taking bisphosphonates; the corresponding numbers among those undiagnosed were four (4.5%) and zero. The authors report that since so few patients had received a proper diagnosis, and fewer still were receiving appropriate therapy, these findings represent an "important lost opportunity to build bone mass and reduce fracture risk in a large patient population." CMAJ 2000;163(7):819-22.

Treating asymptomatic bacteriuria

Despite compelling evidence not to treat asymptomatic bacteruiria in elderly residents of long-term care facilities, such cases frequently are treated. To discover why, researchers conducted four focus groups with physicians and nurses. Ambiguous signs such as foul-smelling urine and subtle changes in patient behaviour were identified as signals for ordering urine cultures and antibiotic therapy. Physicians did not appear to appreciate that that the presence of pyuria in this population is of no diagnostic value.

Other studies have shown that the presence of bacteria in urine without urinary symptoms is common among elderly people living in institutional settings, occurring in up to 50% of elderly women and 35% of elderly men. Also, five randomized trials showed no difference in morbidity or mortality between treated and untreated residents. One such trial showed that antibiotic treatment was associated with more adverse events.

The results generated several research questions, one being, "Do interpretive comments issued with the results of urine screening tests or cultures reduce the frequency of prescribing antibiotics for asymptomatic bacteriuria?" CMAJ 2000;163(3):273-7.

An accompanying commentary identifies the opportunities to move from evidence to practice on this matter. CMAJ 2000;163(3):285-6.

Copyright 2000 Canadian Medical Association or its licensors