Editor’s view—delirium around the world

Worldwide prevalence of delirium

Studies in geriatric medicine seldom come bigger than the stunning worldwide point prevalence study of delirium in hospitals by Lindroth and colleagues [1]. They looked for delirium across a whopping 1664 different wards in 44 countries, assessing for the presence of delirium in almost 80 000 instances. They found delirium in just over one in six hospitalised patients. There were a number of important findings, including high rates of inappropriate benzodiazepine use and variable use of delirium ascertainment methods, such that the rates are probably underestimated. If you missed it, I also recommend reading the group’s previous paper on delirium assessment and protocols published in a previous issue this year [2]. Much still needs to be done to promote delirium awareness, particularly in non-specialist wards across the world.

Diagnosing dementia in minority ethnic communities

People will often live with symptoms of dementia long before they are diagnosed, typically for around 3 years. The delay to diagnosis is even greater among minority ethnic groups. Carter and colleagues explored the pathways to diagnosis in an ethnically diverse area of London [3]. Although qualitative studies involve small sample sizes, they nevertheless provide deeper, valuable insights unattainable in larger quantitative studies. They describe the importance of cultural identity and practices shaping the response to the symptoms of dementia. These may delay asking for help if cultural norms are that roles and responsibilities are passed on with age. There is also an intriguing description of individuals becoming ‘like a tourist’ with daily living becoming unfamiliar in their adopted country. Perhaps most relevantly for clinicians, the term ‘dementia’ was stigmatising in some cultures or unfamiliar or poorly translated in others, such that seeking diagnosis and help for it was challenging. The authors recommend clinicians should familiarise themselves with the additional challenges of dementia in minority ethnic groups.

The menopause and dementia risk

An early menopause confers an increased risk of dementia. In a pooled study of over 233 000 people, experiencing the menopause at age below 40 years conferred a 1.5× increased hazards ratio of developing dementia compared to those who had the menopause in their fifties (P < .01) [4]. This risk is equivalent to being a current smoker and having a previous stroke. The risk was the same regardless of whether the menopause was natural or due to hysterectomy and irrespective of whether the ovaries were retained at surgery. Clinicians should be aware that an early menopause is therefore a major risk factor for developing dementia.

COVID-19 boosters still worthwhile

In a ‘real world’ study of older people who did and did not receive a fourth dose of a recombinant mRNA vaccine against COVID-19, those who received a fourth dose were significantly less likely to become infected, be admitted to hospital or die (all outcome measures individually P < .05) than those who received three [5]. In both groups, the risk of infection, hospitalisation and death was substantially lower where there had been a previous infection. Regardless, the study shows the ongoing value of vaccination against COVID-19, especially for those at highest risk of adverse outcomes, such as our oldest patients. This is important as vaccine fatigue and hesitancy grow, with lower uptake rates of booster vaccinations reported compared to previous years. Everyone that looks after older people has a role in public health and promoting this evidence-based intervention.

Frailty in trials

No issue would be complete without some new insights into frailty. As the gold standard for evaluating interventions, randomised controlled trials (RCTs) should consider frailty if we are to interpret the trial’s applicability to modern day clinical practice. However, the measurement of frailty in RCTs is highly variable. In a comprehensive systematic review of the literature [6], a total of 415 RCTs measured frailty since 2001, when both the frailty phenotype and frailty index were published. The authors found they employed 28 different measures of frailty in addition to a further 29 study-specific measures. This greatly complicates evidence synthesis and interpretation of the data. Moreover, the authors identified the use of measures that were alleged to measure frailty but were actually developed and validated to measure other aspects, such as the Short Physical Performance Battery scale being described as a measure of frailty instead of physical performance. The authors do not think it is likely that a single ‘gold-standard’ measure could ever be agreed or recommended, but would like to minimise variation in measurement (and avoid the proliferation of more measurement tools), develop mapping equations across various measures and encourage participant-level data-sharing.

Guidelines—the good and the bad

We are continuing to champion judicious use of guidelines that apply well to older people, while we sometimes publish articles that warn about those that do not. In our November 2024 issue, we publish two guidelines of interest to geriatricians. In a very focussed but welcome contribution, we present consensus guidelines from the British Heart Rhythm Society on discontinuing implantable defibrillator shock therapy towards the end of life [7]. These should be a useful reference for clinicians finding themselves with such a conundrum. Having recently published the Scottish guideline [8], we now present Italy’s first-ever national guideline on dementia [9]. Both identify and build on areas where previous guidance was perceived to be lacking and emphasise the importance of involving those with dementia in decision-making. However, the Italian guidance is more focussed on the role of clinicians, and I suspect most readers will find it more applicable to their everyday practice. By contrast, a systematic review of guideline recommendations for older people with frailty and type 2 diabetes found considerable variability [10]. Many recommended strict HbA1c targets in otherwise healthy older people but more lax ones where there is frailty. The authors feel this is well evidenced, but overall there were relatively few clinical practice guidelines providing therapeutic recommendations for the management of diabetes in individuals who are frail. As ever, it is important that following guidelines is not used as a substitute for thinking when formulating plans for patients.

Declaration of Conflicts of Interest:

None declared.

Declaration of Sources of Funding:

None.

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