The new england journal of medicine n engl j med 350;25 www.nejm.An 85-year-old man with New York Heart Association class IV heart failure, hypertension, and moderate Alzheimer's disease is admitted to the hospital after a hip fracture. His postoperative course is complicated by pneumonia, delirium, and pressure ulcers on his heels and sacrum. He is losing weight and is unable to participate in rehabilitation because of his confusion. This is his fourth hospitalization in the past year. His 84-year-old wife, who has been caring for him at home, feels overwhelmed by his medical and personal care needs. The patient's physician is increasingly frustrated by his frequent readmissions. What might she do to address his needs, alleviate his suffering, and facilitate his discharge from the hospital and subsequent care at home?By 2030, 20 percent of the U.S. population will be over the age of 65 years. 1 For most people, the years after the age of 65 are a time of good health, independence, and integration of a life's work and experience. Eventually, most adults will have one or more chronic illnesses with which they will live for years before they die. These years are often characterized by physical and psychological distress, progressive functional dependence and frailty, and increased needs for family and external support. 1 Studies suggest that medical care for patients with serious and advanced illnesses is characterized by the undertreatment of symptoms, conflict about who should make decisions about the patient's care, impairments in caregivers' physical and psychological health, and depletion of family resources. 2-5

Objectives: To ascertain the most common causes of delirium, to establish the initiation and timing of delirium, and to determine the duration of delirium in patients with hip fracture.Methods: Five hundred seventy-one (88%) of 650 patients with hip fracture admitted to 4 New York City hospitals were prospectively interviewed on a daily basis, 5 days a week, with the Confusion Assessment Method for the presence of delirium. The patients were enrolled within 48 hours of admission. Their medical charts and the data collected by the study staff were reviewed and summarized. Two of us (R.S.M. and A.L.S.) reviewed the case summaries independently and assigned a cause based on a previously developed classification system, estimated the onset of the delirious episode, and determined whether the delirium had cleared, improved, or persisted at discharge. Subsequently, discrepancies in cause, timing of initiation, and mental status on discharge between the 2 physicians reviewers were discussed until consensus was reached.Results: The prevalence of delirium was 9.5% (54/ 571; 95% confidence interval, 7.0-11.9). Seven percent of episodes were assigned a definite cause, 20% a probable cause, 11% a possible cause, and 61% were attributable to 1 or more comorbid conditions. Twenty-eight (53%) of 54 subjects developed delirium after surgery. The delirium had cleared or improved in 40 (74%) of 54 subjects at the time of discharge.Conclusions: Delirium in patients with hip fracture appears to be a different syndrome from that observed in patients who are otherwise medically ill; it also appears to follow a different clinical course. These results have important implications for the management of delirium in patients with hip fracture.

Although most deaths in the United States occur in hospitals, data suggest that hospitals and physicians are not equipped to handle the medical and psychosocial problems of dying patients. In this article, we review the barriers to achieving a peaceful death, including inadequate medical professional education on palliative care, and public and professional uncertainty about the difference between foregoing life-sustaining treatment and active euthanasia, and health professionals' difficulty recognizing when patients are dying and the associated sense that death is a professional failure. Other barriers include fiscal constraints on the length of stay, the number of nurses available to care for dying patients, legal and regulatory constraints on obtaining opioid prescriptions, and a segregated system of hospice care that requires patients to be separated from familiar health care providers and settings in order to receive palliative care at the end of life. Identifying the opportunities that can improve the delivery of palliative care at the end of life is the first step toward developing corrective approaches. Strategies that enhance these opportunities are proposed.

The patient was admitted to the neurology service. A chest radiograph revealed a density in the right lung apex. Radiographs of the spine The New England Journal of Medicine Downloaded from nejm.org at STOCKHOLMS UNIVERSTITETSBIBL on August 11, 2015. For personal use only. No other uses without permission.

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