Older patients with complex care needs and limited personal and social resources are heavy users of emergency department (ED) services and are often admitted when they present to the ED. Updated information is needed regarding the most effective strategies to appropriately avoid ED presentation and hospital admission among older patients.

This systematic review aimed to identify interventions that have demonstrated effectiveness in decreasing ED use and hospital admissions in older patients. We conducted a comprehensive literature search within Ovid MEDLINE, EMBASE, CINAHL, and Cochrane Central Register of Controlled Trials from database inception to July 2019 with no language restrictions. Interventional study designs conducted in populations of 65 years and older were included. Primary outcomes were ED visits and hospital admissions. Secondary outcomes included hospital readmission, mortality, cost, and patient-reported outcomes.

Of 7,943 citations reviewed for eligibility, 53 studies were included in our qualitative synthesis, including 26 randomized controlled trials (RCT), 8 cluster-RCTs, and 19 controlled before-after studies. Data characterization revealed that community-based strategies reduced ED visits, particularly those that included comprehensive geriatric assessments and home visits. These strategies reported decreases in mean ED use (for interventions versus controls) ranging from -0.12 to -1.32 visits/patient. Interventions that included home visits also showed reductions in hospital admissions ranging from -6% to -14%. There was, however, considerable variability across individual studies with respect to outcome reporting, statistical analyses, and risk of bias, which limited our ability to further quantify the effect of these interventions.

Various interventional strategies to avoid ED presentations and hospital admissions for older patients have been studied. While models of care that include comprehensive geriatric assessments and home visits may reduce acute care utilization, the standardization of outcome measures is needed to further delineate which parts of these complex interventions are contributing to efficacy. The potential effects of multidisciplinary team composition on patient outcomes also warrant further investigation.

Our objective was to determine emergency department (ED) patient adherence to outpatient specialized geriatric services (SGS) following ED evaluation by the geriatric emergency management (GEM) nurse, and identify barriers and facilitators to attendance.

We conducted a prospective cohort study at two academic EDs between July and December 2016, enrolling a convenience sample of patients ≥ 65 years, seen by a GEM nurse, referred to outpatient SGS, and consented to study participation. We completed a chart review and a structured telephone follow-up at 6 weeks. Descriptive statistics were used.

We enrolled 103/285 eligible patients (86 eligible but not enrolled, 86 declined specialized geriatric referrals, and 10 declined study participation). Patients were mean age of 83.1 years, 59.2% female, and 73.2% cognitively impaired. Reasons for referral included mobility (86.4%), cognition (56.3%), pain (38.8%), mood (35.0%), medications (33.0%), and nutrition (31.1%). Referrals were to Geriatric Day Hospital (GDH) programs (50.5%), geriatric outreach (26.2%), falls clinic (12.6%), and geriatric psychiatry (8.7%). Adherence with follow-up was 59.2%. Barriers to attendance included patient did not feel SGS were needed (52.1%), inability to recall GEM consultation (53.4%), and dependence on family for transportation (72.6%). Home-based assessments had the highest adherence (81.5%).

Adherence of older ED patients referred by the GEM team to SGS is suboptimal, and a large proportion of patients decline these referrals in the ED. Future work should examine the efficacy of home-based assessments in a larger confirmatory setting and focus on interventions to increase referral acceptance and address barriers to attendance.

The aim of the present study was to evaluate the association between depression and SSRI monotherapy and frailty both baseline and prospectively in older adults.

Prospective cohort study, 12-month follow-up.

Geriatric outpatient clinic in São Paulo, Brazil.

A total of 811 elderly adults aged 60 or older.

Depression was diagnosed as follows: (1) a diagnosis of major depression disorder (MDD) according to DSM-5; or (2) an incomplete diagnosis of MDD, referred to as minor or subsyndromic depression, plus Geriatric Depression Scale 15-itens ≥ 6 points, and social or functional impairment secondary to depressive symptoms and observed by relatives. Frailty evaluation was performed through the FRAIL questionnaire, which is a self-rated scale. Trained investigators blinded to the baseline assessment conducted telephone calls to evaluate frailty after 12-month follow-up. The association between depression and the use of SSRI with frailty was estimated through a generalized estimating equation adjusted for age, gender, total drugs, and number of comorbidities.

Depression with SSRI use was associated with frailty at baseline (OR 2.82, 95% CI = 1.69–4.69) and after 12 months (OR 2.75, 95% CI = 1.84–4.11). Additionally, depression with SSRI monotherapy was also associated with FRAIL subdomains Physical Performance (OR 1.99, 95% CI = 1.29–3.07) and Health Status (OR 4.64, 95% CI = 2.11–10.21). SSRI use, without significant depressive symptoms, was associated with subdomain Health Status (OR 1.52, 95% CI = 1.04–2.23).

It appears that depression with SSRI is associated to frailty, and this association cannot be explained only by antidepressant use.

The risks of polypharmacy can be far greater than the benefits, especially in the elderly. Comorbidity makes polypharmacy very prevalent in this population; thus, increasing the occurrence of adverse effects. To solve this problem, the most common strategy is to use lists of potentially inappropriate medications. However, this strategy is time consuming.

In order to minimize the expenditure of time, our group devised a pilot computer tool (Polimedication) that automatically processes lists of medication providing the corresponding Screening Tool of Older Persons’ potentially inappropriate Prescriptions alerts and facilitating standardized reports. The drug lists for 115 residents in Santa Marta Nursing Home (Fundación San Rosendo, Ourense, Spain) were processed.

The program detected 10.04 alerts/patient, of which 74.29% were not repeated. After reviewing these alerts, 12.12% of the total (1.30 alerts/patient) were considered relevant. The largest number of alerts (41.48%) involved neuroleptic drugs. Finally, the patient's family physician or psychiatrist accepted the alert and made medication changes in 62.86% of the relevant alerts. The largest number of changes (38.64%) also involved neuroleptic drugs. The mean time spent in the generation and review of the warnings was 6.26 minute/patient. Total changes represented a saving of 32.77 € per resident/year in medication.

The application of Polimedication tool detected a high proportion of potentially inappropriate prescriptions in institutionalized elderly patients. The use of the computerized tool achieved significant savings in pharmaceutical expenditure, as well as a reduction in the time taken for medication review.

Switching between antidepressants is complex due to potential adverse outcomes such as serotonin syndrome and antidepressant discontinuation syndrome, yet switching is often required due to non-response to initial treatment. This study aimed to examine the patterns and extent of antidepressant switching in a cohort of older adults in long-term residential care.

A cohort study of medication supply data from 6011 aged care residents in 60 long-term care facilities was conducted. Incident antidepressant users were followed for 12 months and their patterns of antidepressant use determined. The type of switching from and to different antidepressant classes was determined according to National and International recommendations for antidepressant switching.

In total, 11% (n = 44) of the residents were initiated on an antidepressant medication (n = 402) switched to a different antidepressant agent within 12 months. Residents commenced on a SNRI or TCA were most likely to switch antidepressants (17% in each group). Almost half of the switches (n = 21, 48% of all switches) were not implemented according to guideline recommendations. Direct switch and taper followed by wash out and switch, accounted for all of the inappropriate switching (29% and 71%, respectfully), with half occurring to mirtazapine (N = 7) or from mirtazapine (N = 3).

Over one in 10 long-term aged care residents who commence an antidepressant will switch to a different antidepressant within 12 months. Current antidepressant switching practices in long-term residential aged care may be increasing the risk of harm associated with antidepressant switching, with around half of all switches not following current guideline recommendations.

Memory deficits are dominant in dementia and are positively correlated with electroencephalographic (EEG) beta power. EEG beta power can predict the progression of Alzheimer´s (AD) as early as at the stage of mild cognitive impairment (MCI) and could possibly be used as surrogate marker for memory impairment. The objective of this study is to analyze the relationship between frontal and parietal EEG beta power and memory-test outcome. Frontal and parietal beta power is analyzed for a resting state and an eyes-closed backward counting condition and related to memory impairment parameters.

A total of 28 right-handed female geriatric patients (mean age = 80.6) participated voluntarily in this study. Beta 1 (12.9–19.2 Hz) and beta 2 (19.2–32.4 Hz) EEG power at F3, F4, Fz, P3, P4, and Pz are correlated with immediate wordlist recall, delayed wordlist recall, recognition of learned words, and delayed figure recall. For classification between impaired and intact memory, we calculated a binary logistic regression model with memory impairment as a dependent variable and beta 2 power as an independent variable.

We found significant positive correlations between frontal and parietal beta power and delayed memory recall. A significant correlation (Bonferroni correction, p < 0.05) was found at F4 beta 2 during backward counting. The binary logistic regression model with F4 beta 2 power during the counting condition as a predictor yielded a sensitivity of 76.9% (95% CI) and a specificity of 73.3% (95% CI) for classifying patients into “verbal-memory impaired” and “intact.”

EEG beta 2 power recorded during a backward counting condition with eyes closed can be used as surrogate marker for verbal memory impairment in geriatric patients. Antidepressant treatment was correlated with EEG data in resting state but not in counting condition. Further studies are necessary to verify the results of this pilot study.

A consequence of pressure on hospitals to accommodate care needs of older patients is “boarding” or out-lying from their home ward. This may have greater adverse effects on older inpatients who are frail.

A retrospective matched cohort study was conducted in an outer metropolitan general hospital. Randomly selected patients hospitalized between July 2012 and June 2013 under the care of an Older Person Evaluation Review and Assessment (OPERA) team (n = 300) were age and sex matched with patients under the care of general physicians (n = 300). Frequency of boarding and number of bed moves were recorded for all patients. For patients who had three or more moves, adverse outcomes were compared between the two groups.

A higher proportion of OPERA patients (n = 143; 47.7%) were out-lied from medical wards compared with 94 (31.3%) General Medicine patients (p < 0.001). Three or more bed moves were recorded for 67 (22.3%) OPERA and 24 (8%) General Medicine patients (p < 0.001). Of those with multiple moves, OPERA patients were more likely to have pre-morbid cognitive impairment (p = 0.005), to be moderately to severely frail (p = 0.016) and to suffer acute delirium and falls during admission (p = 0.03), compared with General Medicine patients. OPERA patients were also more at risk of adverse outcomes such as increased dependence, discharge to residential care or death (p = 0.023).

Compared with age- and sex-matched General Medicine patients, OPERA patients were more likely to undergo multiple bed moves and out-lying, which may have contributed to negative outcomes for these patients.

Age-related cognitive decline is common and well-documented. Cognitive speed of processing training (SOPT) has been shown to improve trained abilities (Useful Field of View; UFOV), but transfer to individual non-trained cognitive outcomes or neuropsychological composites is sparse. We examine the effects of SOPT on a composite of six equally weighted tests – UFOV, Trail-making A and B, Symbol Digit Modality, Controlled Oral Word Association, Stroop Color and Word, and Digit Vigilance.

681 patients were randomized separately within two age-bands (50–64, ≥ 65) to three SOPT groups (10 initial hours on-site, 10 initial hours on-site plus 4 hours of boosters, or 10 initial hours at-home) or an attention-control group (10 initial hours on-site of crossword puzzles). At one-year, 587 patients (86.2%) had complete data. A repeated measures linear mixed model was used.

Factor analysis revealed a simple unidimensional structure with Cronbach's α of 0.82. The time effect was statistically significant (p < 0.001; ηp2 = 0.246), but the time by treatment group (p = 0.331), time by age-band (p = 0.463), and time by treatment group by age-band (p = 0.564) effects were not.

Compared to the attention-control group who played a computerized crossword puzzle game, assignment to 10–14 hours of SOPT did not significantly improve a composite measure of cognitive abilities.