Importance Major postoperative complications and delirium contribute independently to adverse outcomes and high resource utilization in patients undergoing major surgery; however, their inter-relationship is not well-examined. Objective To evaluate the association of major postoperative complications and delirium, alone and in combination, with adverse outcomes after surgery. Design Prospective cohort study. Setting Two large academic medical centers. Participants Patients without recognized dementia or history of delirium, age 70 and older who underwent elective major orthopedic, vascular, and abdominal surgeries with a minimum 3-day hospitalization. Main Outcome and Measures Major postoperative complications, defined as life altering or threatening events (Accordion Severity ≥ grade 2), were identified by expert panel adjudication. Delirium was measured daily with the Confusion Assessment Method and a validated chart review method. Four subgroups were analyzed: (1) no complications, no delirium; (2) complications alone; (3) delirium alone; and (4) both complications and delirium. Adverse outcomes included length of stay (LOS) > 5 days, institutional discharge, and rehospitalization within 30 days of discharge. Results Of 566 participants, mean age (±SD) was 76.7± 5.2 years, 42% male and 92% white. Forty-seven (8%) developed major complications, and 135 (24%) developed delirium. When compared to no complications, no delirium as the reference group, major complications alone contributed only to prolonged LOS (RR 2.8, 95% CI 1.9–4.0); by contrast, delirium alone significantly increased all adverse outcomes, including prolonged LOS (RR 1.9, 95% CI 1.4–2.7), institutional discharge (RR 1.5, 95% CI 1.3–1.7), and 30-day readmission (RR 2.3, 95% CI 1.4–3.7). The subgroup with both complications and delirium had the highest rates of all adverse outcomes, including prolonged LOS (RR 3.4, 95% CI 2.3–4.8), institutional discharge (RR 1.8, 95% CI 1.4–2.5) and 30-day readmission (RR 3.0, 95% CI 1.3–6.8). Delirium exerted the highest attributable risk at a population level (5.8%, 95% CI 4.7–6.8) compared with all other adverse events (prolonged LOS, institutional discharge, or readmission). Conclusions and Relevance Major postoperative complications and delirium are separately associated with adverse events and demonstrate a strong combined effect. Delirium occurs more frequently, and has greater impact at the population level than other major complications.

Frailty, measured by the FRAIL scale, was associated with increase LOS, complications after surgery, and discharge to rehabilitation facility in geriatric fracture patients. The FRAIL scale is a promising short screen to stratify and help operationalize the perioperative care of older surgical patients.

Background/Objectives Preoperative frailty has been associated with poor postoperative outcomes after orthopedic surgery; however frailty measures have not been compared in this population. We applied the Frailty Phenotype (FP) and Frailty Index (FI) before major elective orthopedic surgery to categorize frailty status and assessed association with postoperative outcomes. Design Prospective cohort study. Setting Two tertiary hospitals in Boston, MA. Participants 415 patients aged ≥70 years undergoing scheduled orthopedic surgery enrolled in SAGES: Successful Aging after Elective Surgery (SAGES) Study. Measurements Preoperative evaluation included assessment of frailty using the FP and FI. We used the weighted kappa statistic to determine concordance between the 2 frailty measures and multivariable modeling to determine associations between each measure and postoperative complications, postoperative length of stay (LOS) >5 days, discharge to post acute (PAC) institutional care, and 30 day readmission. Results Frailty was highly prevalent (FP 35%, FI 41%). There was moderate concordance between the FP and FI (kappa=.42, 95% confidence interval (CI) .36,.49). When using FP, compared to the robust group, being pre-frail predicted higher risk of complications (RR 1.6, 95% CI 1.1,2.1) and PAC (RR 1.8, 95% CI 1.2,2.9);being frail predicted complications (RR 1.7, 95% CI 1.1,2.1), LOS >5 days (RR 3.1, 95% CI 1.1,8.8), and PAC(RR 2.3 95% CI 1.4,3.7). When using FI, being pre-frail predicted LOS > 5 days (RR 2.1, 95% CI 1.0,4.8), and PAC (RR 1.5, 95% CI 1.4,2.1) as did being frail (RR=1.9, 95% CI 1.4,2.5; and RR 3.1, 95% CI 1.4,6.8 respectively).. The other outcomes were not significantly associated with frailty status. Conclusion Both FP and FI predict postoperative outcomes after major elective orthopedic surgery, and should be considered for preoperative risk stratification.

Background and Objectives: While there are qualitative studies examining the delirium-related experiences of patients, family caregivers, and nurses separately, little is known about common aspects of delirium burden among all three groups. We describe common delirium burdens from the perspectives of patients, family caregivers, and nurses. Research Design and Methods: We conducted semistructured qualitative interviews about delirium burden with 18 patients who had recently experienced a delirium episode, with 16 family caregivers, and with 15 nurses who routinely cared for patients with delirium. We recruited participants from a large, urban teaching hospital in Boston, Massachusetts. Interviews were recorded and transcribed. We used interpretive description as the approach to data analysis. Results: We identified three common burden themes of the delirium experience: Symptom Burden (Disorientation,

Importance: Measurement of delirium severity has been recognized as highly important for tracking prognosis, monitoring response to treatment, and estimating burden of care both during and after hospitalization. Rather than simply rating delirium as present or absent, the ability to quantify its severity will enable development and monitoring of more effective treatment approaches for delirium. Objective: This study had 3 major goals: to present a comprehensive review of delirium severity instruments; to conduct a methodologic quality rating of the original validation study of the most commonly used instruments; and to select a group of top-rated instruments. Evidence Review: Using key words, subject headings, and full text approaches, we conducted a systematic review of the following databases,

The prevalence of human immunodeficiency virus (HIV) infection among people older than 50 years is increasing. Older HIV-infected patients are particularly at risk for polypharmacy because they often have multiple comorbidities that require pharmacotherapy. Overall, there is not much known with respect to both the impact of aging on medication use in HIV-infected individuals, and the potential for interactions with highly active antiretroviral therapy (HAART) and coadministered medications and its clinical consequences. In this review, we aim to provide an overview of polypharmacy with a focus on its impact on the HIV-infected older adult population and to also provide some clinical considerations in this high-risk population.

Objectives-To characterize the beliefs and opinions of nursing home (NH) and emergency medicine providers about communication between NH and emergency departments (ED) during transitions of care of NH residents.Design-A cross-sectional study using a mailed and internet survey.Participants and Setting-Physicians, nurse practitioners, physician's assistants and nurses who practice in ED settings and NH settings, affiliated with hospitals of an academic medical center in Rochester, New York. Measurements-Opinions on communication; beliefs about frequency of information transmission; opinions on how often verbal communication should occur.Results-A total of 155 nurses and medical providers participated in the survey for a response rate of 32.2% (155/481). Of the survey participants, 63.0% and 56.8% had been more than 5 years in their position and facility, respectively. The majority of respondents felt that important information was lost during patient transfers between NH and ED settings. Providers from ED and NH settings had different opinions on the likelihood that key information would be readily identifiable at patient transfer and that care would include requested tests and follow-up. Providers from both sites of care supported verbal communication at their position when NH residents are transferred to the other setting.Conclusion-Nurses and medical providers from both emergency and NH settings agree that transitional communication is poor between NHs and EDs and support a role for verbal communication during the ED transitions of care of NH residents.

Active management in a GFC model to reverse anticoagulation before surgery may facilitate earlier surgery without increasing observed complications.