'Across the pond'—a response to the NICE guidelines for management of multi-morbidity in older people

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Thyroid hormone therapy for older adults with subclinical hypothyroidism

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Informant single screening questions for delirium and dementia in acute care – a cross-sectional test accuracy pilot study

Background Cognitive impairment often goes undetected in older people in hospital. Efficient screening tools are required to improve detection.<p></p> To determine diagnostic properties of two separate informant-based single screening questions for cognitive impairment (dementia and delirium) in hospitalised older people.<p></p> Methods Patients over 65 years non-electively admitted to medical or geriatric wards within a teaching hospital. Our index tests were single screening questions (SSQ), one for dementia (“How has your relative/friend’s memory changed over the past 5 years (up to just before their current illness)?”) and one for delirium (“How has your relative/friend’s memory changed with his/her current illness?”), which were assessed with informant response given on a five point Likert scale.<p></p> Any deterioration on our index tests of SSQ-dementia and SSQ-delirium was accepted as a positive screen for cognitive impairment. Scores were compared to the Informant Questionnaire for Cognitive Decline in the Elderly (IQCODE) >3.38 accepted as dementia, and Confusion Assessment Method (CAM) diagnosis of delirium. We also collected direct cognitive screening data using Mini Mental Status Examination (MMSE).<p></p> Results Informant responses were obtained in 70/161 (43.5%) patients, median age 80.8 (range:67–97) years; mean MMSE score 18.5 (SD: 8.1). The SSQ-dementia when compared to the IQCODE had a sensitivity of 83.3% and specificity of 93.1%. The SSQ-delirium when compared to CAM diagnosis had sensitivity of 76.9% and a specificity of 56.1%.<p></p> Conclusions These findings show promise for use of an informant single screening question tool as the first step in detection of dementia in older people in acute hospital care, although this approach appears to be less accurate in screening for delirium.<p></p&gt

Managing blood pressure in older adults

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Conducting and reporting trials for older people

Randomised controlled trials provide the most rigorous test of efficacy and effectiveness for interventions used in healthcare. They underpin much of clinical practice, yet older people are often excluded from studies, resulting in uncertainty about risks and benefits of new treatments. Encouraging inclusion of older people in randomised controlled trials and reporting of trial results in a rigorous manner is a key function of clinical geriatrics journals such as Age and Ageing. This article provides practical advice on how to report randomised controlled trials that are targeted at older people. Some of these issues are generic, but there are specific requirements which apply to most studies of older people. Recording and reporting basic characteristics of recruits in terms of physical function, cognition, comorbidity and/or frailty is vital to allow proper interpretation of the external validity of the trial. Adverse effects should include consideration of common geriatric problems including falls. Authors should follow the CONSORT reporting guidelines (CONsolidated Standards Of Reporting Trials) to enhance the transparency and quality of their manuscript

Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) for the diagnosis of dementia within community dwelling populations

<b>Background</b><p></p> Various tools exist for initial assessment of possible dementia with no consensus on the optimal assessment method. Instruments that use collateral sources to assess change in cognitive function over time may have particular utility. The most commonly used informant dementia assessment is the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE).<p></p> A synthesis of the available data regarding IQCODE accuracy will help inform cognitive assessment strategies for clinical practice, research and policy.<p></p> <b>Objectives</b><p></p> Our primary objective was to determine the diagnostic accuracy of the informant based questionnaire IQCODE, for detection of all cause (undifferentiated) dementia in community-dwelling adults with no previous cognitive assessment. We sought to describe the accuracy of IQCODE (the index test) against a clinical diagnosis of dementia (the reference standard).<p></p> Our secondary objective was to describe the effect of heterogeneity on the summary estimates. We were particularly interested in the traditional 26-item scale versus the 16-item short form; and language of administration. We explored the effect of varying the threshold IQCODE score used to define 'test positivity'.<p></p> <b>Search methods</b><p></p> We searched the following sources on 28 January 2013: ALOIS (Cochrane Dementia and Cognitive Improvement Group), MEDLINE (OvidSP), EMBASE (OvidSP), PsycINFO (OvidSP), BIOSIS Previews (ISI Web of Knowledge), Web of Science with Conference Proceedings (ISI Web of Knowledge), LILACS (BIREME). We also searched sources relevant or specific to diagnostic test accuracy: MEDION (Universities of Maastrict and Leuven); DARE (York University); ARIF (Birmingham University). We used sensitive search terms based on MeSH terms and other controlled vocabulary.<p></p> <b>Selection criteria</b><p></p> We selected those studies performed in community settings that used (not necessarily exclusively) the IQCODE to assess for presence of dementia and, where dementia diagnosis was confirmed, with clinical assessment. Our intention with limiting the search to a 'community' setting was to include those studies closest to population level assessment. Within our predefined community inclusion criteria, there were relevant papers that fulfilled our definition of community dwelling but represented a selected population, for example stroke survivors. We included these studies but performed sensitivity analyses to assess the effects of these less representative populations on the summary results.<p></p> <b>Data collection and analysis</b><p></p> We screened all titles generated by the electronic database searches and abstracts of all potentially relevant studies were reviewed. Full papers were assessed for eligibility and data extracted by two independent assessors. For quality assessment (risk of bias and applicability) we used the QUADAS 2 tool. We included test accuracy data on the IQCODE used at predefined diagnostic thresholds. Where data allowed, we performed meta-analyses to calculate summary values of sensitivity and specificity with corresponding 95% confidence intervals (CIs). We pre-specified analyses to describe the effect of IQCODE format (traditional or short form) and language of administration for the IQCODE.<p></p> <b>Main results</b><p></p> From 16,144 citations, 71 papers described IQCODE test accuracy. We included 10 papers (11 independent datasets) representing data from 2644 individuals (n = 379 (14%) with dementia). Using IQCODE cut-offs commonly employed in clinical practice (3.3, 3.4, 3.5, 3.6) the sensitivity and specificity of IQCODE for diagnosis of dementia across the studies were generally above 75%.<p></p> Taking an IQCODE threshold of 3.3 (or closest available) the sensitivity was 0.80 (95% CI 0.75 to 0.85); specificity was 0.84 (95% CI 0.78 to 0.90); positive likelihood ratio was 5.2 (95% CI 3.7 to 7.5) and the negative likelihood ratio was 0.23 (95% CI 0.19 to 0.29).<p></p> Comparative analysis suggested no significant difference in the test accuracy of the 16 and 26-item IQCODE tests and no significant difference in test accuracy by language of administration. There was little difference in sensitivity across our predefined diagnostic cut-points.<p></p> There was substantial heterogeneity in the included studies. Sensitivity analyses removing potentially unrepresentative populations in these studies made little difference to the pooled data estimates. The majority of included papers had potential for bias, particularly around participant selection and sampling. The quality of reporting was suboptimal particularly regarding timing of assessments and descriptors of reproducibility and inter-observer variability.<p></p> <b>Authors' conclusions</b><p></p> Published data suggest that if using the IQCODE for community dwelling older adults, the 16 item IQCODE may be preferable to the traditional scale due to lesser test burden and no obvious difference in accuracy. Although IQCODE test accuracy is in a range that many would consider 'reasonable', in the context of community or population settings the use of the IQCODE alone would result in substantial misdiagnosis and false reassurance. Across the included studies there were issues with heterogeneity, several potential biases and suboptimal reporting quality

Evaluation of delirium screening tools in geriatric medical inpatients: a diagnostic test accuracy study

Introduction: screening all unscheduled older adults for delirium is recommended in national guidelines, but there is no consensus on how to perform initial assessment. Aim: to evaluate the test accuracy of five brief cognitive assessment tools for delirium diagnosis in routine clinical practice. Methods: a consecutive cohort of non-elective, elderly care (older than 65 years) hospital inpatients admitted to a geriatric medical assessment unit of an urban teaching hospital. Reference assessments were clinical diagnosis of delirium performed by elderly care physicians. Routine screening tests were: Abbreviated Mental Test (AMT-10, AMT-4), 4 A's Test (4AT), brief Confusion Assessment Method (bCAM), months of the year backwards (MOTYB) and informant Single Question in Delirium (SQiD). Results: we assessed 500 patients, mean age 83 years (range = 66−101). Clinical diagnoses were: 93 of 500 (18.6%) definite delirium, 104 of 500 (20.8%) possible delirium and 277 of 500 (55.4%) no delirium; 266 of 500 (53.2%) were identified as definite or possible dementia. For diagnosis of definite delirium, AMT-4 (cut-point < 3/4) had a sensitivity of 92.7% (95% confidence interval (CI): 84.8–97.3), with a specificity of 53.7% (95% CI: 48.1–59.2); AMT-10 (<4/10), MOTYB (<4/12) and SQiD showed similar performance. bCAM had a sensitivity of 70.3% (95% CI: 58.5–80.3) with a specificity of 91.4% (95% CI: 87.7–94.3). 4AT (>4/12) had a sensitivity of 86.7% (95% CI: 77.5–93.2) and specificity of 69.5% (95% CI: 64.4–74.3). Conclusions: short screening tools such as AMT-4 or MOTYB have good sensitivity for definite delirium, but poor specificity; these tools may be reasonable as a first stage in assessment for delirium. The 4AT is feasible and appears to perform well with good sensitivity and reasonable specificity