This study is an important update of previously established criteria that have been widely used and cited. The application of the Beers criteria and other tools for identifying potentially inappropriate medication use will continue to enable providers to plan interventions for decreasing both drug-related costs and overall costs and thus minimize drug-related problems.

Delirium in a patient with preexisting dementia is a common problem that may have serious complications and poor prognostic implications. The purpose of this paper was to conduct a systematic review of the medical literature on delirium superimposed on dementia, specifically to review studies on prevalence, associated features, outcomes, and management. Areas of controversy and gaps in our knowledge of this problem are highlighted. Finally, an agenda for future research is proposed. Fourteen studies were reviewed, including seven prospective studies, three retrospective studies, two cross-sectional studies, and two clinical trials. For the review of the literature on delirium superimposed on dementia, we searched MEDLINE from January 1966 through February 2002 for research studies with primary sources of data. Selection criteria for inclusion of articles in this study were inclusion of data on subjects with delirium superimposed on dementia, inclusion of a validated operational definition/measures of dementia and delirium, actual data on persons with delirium and dementia reported in the paper, and reporting of primary data. MEDLINE was searched using the following key search terms: delirium, acute confusion, cognitive impairment, Alzheimer's disease, dementia, delirium superimposed on dementia, and elderly. The prevalence of delirium superimposed on dementia ranged from 22% to 89% of hospitalized and community populations aged 65 and older with dementia. To date, only one reported study systematically identified associated factors and interventions for delirium superimposed on dementia, but several studies examining outcomes have found that adverse events are associated with delirium in persons with dementia, including accelerated and long-term cognitive and functional decline, need for institutionalization, rehospitalization, and increased mortality. This paper highlights the dearth of research on delirium superimposed on dementia and stresses the importance of early recognition and prevention of delirium in persons with dementia.

The purpose of this study was to examine the prevalence of potentially inappropriate medication use (PIMs) among community-dwelling older adults and the association between PIMs and health care outcomes. Participants were 17,971 individuals age 65 years and older. PIM use was defined by the Beers criteria. Drug-related problems (DRPs) were defined using ICD-9 codes. Forty percent of the 17,971 individuals filled at least 1 PIM prescription, and 13% filled 2 or more PIM prescriptions. Overall DRP prevalence among those with at least 1 PIM prescription was 14.3% compared to 4.7% in the non-PIM group (p < .001). In conclusion, preventing PIM use may be important for decreasing medication-related problems, which are increasingly being recognized as requiring an integrated interdisciplinary approach. Keywordsmedications; healthcare costs; geriatrics; adverse drug events Drug-related problems (DRPs) are prevalent in the older adult population and pose a major patient safety concern. DRPs arise because of the increasing number of medications required by this age group, fragmented systems of care, pre-existing health conditions, and the pharmacokinetic and pharmacodynamic changes that occur with aging (Bigos, Bies, & Pollock, 2006;Cusack, 2004;Gurwitz, 2004;Hajjar et al., 2003;Turnheim, 2004Turnheim, , 2005. Avoiding use of high-risk drugs is an important strategy in reducing DRPs. The purpose of this study was to examine both the prevalence of potentially inappropriate medication (PIMs) use among community-dwelling older adults and the association between PIMs and health care outcomes.One method promoted to identify high-risk medications is the use of an explicit list of PIMs. PIMs were first devised and publicized by Beers et al. for nursing home residents and subsequently expanded to include older adults in all settings (Beers, 1997). PIMs are medications identified through expert panel review as having risks that outweigh benefits (Beers et al., 1991). Since the early 1990s, the prevalence of PIMs has been examined in a (Lau, Kasper, Potter, & Lyles, 2004), outpatient (Aparasu & Sitzman, 1999Curtis et al., 2004), acute care (Onder et al., 2005), and community settings (Zhan et al., 2001). For research purposes, use of explicit criteria is generally preferred over the use of implicit criteria applied by expert reviewers.The clinical validity of using a list of medications based on expert panel review and explicit criteria has been questioned as being overly simplistic and not including all the common drugs causing problems in older adults (Crownover & Unwin, 2005;Shorr, 2004). Moreover, despite the numerous reports of the prevalence of PIMs, only a few investigators (Fu, Liu, & Christensen, 2004;Thapa, Gideon, Cost, Milam, & Ray, 1998) have examined whether PIMs are associated with adverse clinical outcomes. Therefore, we investigated the outcomes associated with PIM use in a population of community-dwelling older adults.The Beers criteria have been revised recently; hence, the current prevalence of PIMs in...

The postoperative delirium in older adults guideline project was initiated by selecting an interdisciplinary, multi-specialty 23 member panel. The panel was chosen by the American Geriatrics Society's Geriatrics-for-Specialists Initiative (AGS-GSI) council with additional input from the panel co-chairs, with the goal of selecting participants with special interest and expertise in postoperative delirium. Represented disciplines included the fields of geriatric medicine, general surgery, anesthesiology, emergency medicine, geriatric surgery, gynecology, hospital medicine, critical care medicine, neurology, neurosurgery, nursing, obstetrics and gynecology, orthopedic surgery, ophthalmology, otolaryngology, palliative care, pharmacy, psychiatry, physical medicine and rehabilitation, thoracic surgery, urology, and vascular surgery.Additional ex officio panel members included a representative from the National Committee for Quality Assurance (NCQA), a quality measures expert, and a caregiver representative. The following panel members served on the writing group for this best practices statement: Stacie Deiner, MD;Conflicts of interest were disclosed initially and updated three times during guideline development. Disclosures were reviewed by the entire panel and potential conflicts resolved by the co-chairs (see Appendix 1). LITERATURE REVIEWThe methods for postoperative delirium risk factors, screening (case finding), and diagnosis (Table 1, Topics I to III) were distinct from the other aims, because these topics were thoroughly addressed in recent high-quality guideline statements and systematic reviews upon which the recommendation statements in these sections were based. 4,20-22 Additionally, these topics were considered outside the scope of the main literature search, which focused on prevention and treatment of delirium in the perioperative setting. Key citations were included in the section summaries. Sections were drafted by panel groups and then refined with the committee co-chairs. Subsequently, full consensus of the panel was achieved for all recommendation statements and summary sections.The methods for the literature search for the aims addressing the pharmacologic and nonpharmacologic interventions for the prevention or treatment of postoperative delirium in older adults (Table 1, Topics IV to X) included comprehensive searches, targeted searches, and focused searches. A more detailed description of the search methods is found in the accompanying clinical guideline document. 19 Comprehensive searches (1988( to December 2013 in PubMed, Embase, and CINAHL used the search terms delirium, organic brain syndrome, and acute confusion and resulted in a total of 6,504 articles. Additional, alternative terms included for the prevention and treatment of delirium were the words prevention, management, treatment, intervention, therapy, therapeutic, and drug therapy. Two additional targeted searches using the U.S. Library of National Medicine PubMed Special Queries on Comparative EffectivenessResearch and PubMed Cli...

Background The Beers list of potentially inappropriate medications (PIMs) provides a key indicator of medication prescribing quality. The criteria were updated in 2012, adding new drugs and assessing evidence strength. Objectives To use the most recently available population-based data to estimate PIM prevalence under the 2012 update and to provide a benchmark from which to measure future changes. Design and Setting Retrospective cohort study using nationally representative data from the 2006–2010 Medical Expenditure Panel Survey (MEPS). Participants Community-dwelling sample of US older adults (n = 18,475). Measurements We operationalized the updated Beers criteria, generating a “broad” PIM definition that incorporated form, route or dose restrictions where clearly specified and a “qualified” definition that applied specific exceptions where mentioned in the rationale associated with each drug category. Bivariate analyses described PIM prevalence, comparing the two operational definitions, and examined time trends. Results Among older adults with prescription medications, 42.6% had at least one medication fill that met the broad definition, with non-steroidal anti-inflammatory drugs (NSAIDs) having the highest (10.9%) prevalence. The rate declined from 45.5% in 2006–2007 to 40.8% in 2009–2010. The categories with the largest absolute decline were NSAIDs, selected sulfonylureas, and estrogens. PIM prevalence was 30.7% using the qualified definition. Conclusion Despite the overall high use of PIMs, there has been a decline observed in recent years. Future studies should test the effect of educational and clinical interventions on changes in PIM use and patient outcomes. The current study results can aid in targeting these interventions.

Background Current literature does not identify the significance of underlying cognitive impairment and delirium on older adults during and 30 days following acute care hospitalization. Objective Describe the incidence, risk factors, and outcomes associated with incident delirium superimposed on dementia. Design 24-month prospective cohort study Setting community hospital Patients 139 older adults (>65 years) with dementia Methods This prospective study followed patients daily during hospitalization and one month post-hospital. Main measures included dementia (Modified Blessed Dementia Rating Score, IQ CODE), daily mental status change, dementia stage/severity (Clinical Dementia Rating, Global Deterioration Scale), delirium (Confusion Assessment Method), and delirium severity (Delirium Rating Scale-Revised-98). All statistical analysis was performed using SAS 9.3 and significance with an alpha level of 0.05. Logistic regression, analysis of covariance or linear regression was performed controlling for age, gender and dementia stage. Results The overall incidence of new delirium was 32% (44/140). Those with delirium had a 25% short term mortality rate, increased length of stay and poorer function at discharge. At one month follow-up, subjects with delirium had greater functional decline. Males were more likely to develop delirium and for every one unit increase in dementia severity (Global Deterioration Scale), subjects were 1.5 times more likely to develop delirium. Conclusions Delirium prolongs hospitalization for persons with dementia. Thus, interventions to increase early detection of delirium have the potential to decrease the severity and duration of delirium and to prevent unnecessary suffering and costs from the complications of delirium and unnecessary readmissions to the hospital.

To describe the prevalence of potentially inappropriate medication (PIM) use (defined by the Beers criteria) and association with resource utilization in a Medicare managed care population. METHODS: Retrospective review of a health maintenance organization (HMO) administrative database claims data for a subset of Medicare managed care patients 65 years of age and older to compare persons on PIMs (cases) with persons not on PIMs (comparisons). Measures included costs, inpatient and outpatient utilization, number of prescriptions, patient demographics, diagnoses, prescriber information, clinical data including self-rated health, and the Charlson Comorbidity Index. RESULTS: The prevalence of PIM use in this Medicare managed care population was 24.2% (541/2,336). Eightyeight of the 146 individuals on two or more inappropriate medications had 4-13 providers prescribing all their medications. Those on a PIM had significantly higher total, provider, and facility costs, and a higher mean number of inpatient, outpatient, and emergency room visits than comparisons after controlling for sex, Charlson comorbidity index, and total number of prescriptions. CONCLUSIONS: Our study revealed a high prevalence of potentially inappropriate medication use among older adults in a managed care plan and an association with high resource utilization. In this study, we sought to gather evidence to guide the future development of an intervention and educational program to decrease the use of high-risk medications in older adults.

Delirium occurring in patients with dementia is referred to as delirium superimposed on dementia (DSD). People who are older with dementia and who are institutionalized are at increased risk of developing delirium when hospitalized. In addition, their prior cognitive impairment makes detecting their delirium a challenge. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition and the International Statistical Classification of Diseases and Related Health Problems, 10th Revision are considered the standard reference for the diagnosis of delirium and include criteria of impairments in cognitive processes such as attention, additional cognitive disturbances, or altered level of arousal. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition and the International Statistical Classification of Diseases and Related Health Problems, 10th Revision does not provide guidance regarding specific tests for assessment of the cognitive process impaired in delirium. Importantly, the assessment or inclusion of preexisting cognitive impairment is also not addressed by these standards. The challenge of DSD gets more complex as types of dementia, particularly dementia with Lewy bodies, which has features of both delirium and dementia, are considered. The objective of this article is to critically review key elements for the diagnosis of DSD, including the challenge of neuropsychological assessment in patients with dementia and the influence of particular tests used to diagnose DSD. To address the challenges of DSD diagnosis, we present a framework for guiding the focus of future research efforts to develop a reliable reference standard to diagnose DSD. A key feature of a reliable reference standard will improve the ability to clinically diagnose DSD in facility-based patients and research studies.