IntroductionOut-of-hours (OOH) services provide urgent primary care outside normal General Practice (GP) hours, serving patients who cannot wait for routine service. Delirium is commonly associated with acute illness, causes distress and leads to poor outcomes. However, little is known about delirium presentations in OOH services. We aimed to investigate using records from an OOH service in South-West England.MethodsThe database contained 33 345 contacts with patients ≥65 years attending the OOH service. We screened consultations during April and July 2019, and January 2020 using an automated search then clinical review by two independent GPs. We validated our search strategy by reviewing a random sample of 100 ‘search-negative’ consultations initially and assessed inter-rater reliability. Patient characteristics were compared using Chi-squared tests.ResultsOf 4288 consultations with patients ≥65 years in the study periods, 402 (9.4%) involved possible or probable delirium. A further 74 (1.7%) had end-of-life delirium and were excluded from further analysis. Patients with delirium were older (mean age 84.4 years vs. 80.1 years), and more often had dementia (46.6% vs. 10.4%, P < .001). 67.9% of delirious patients required home visits, compared to 22.2% without delirium (P < .001). Patients with delirium were admitted to hospital twice as often as those without (20.6% vs. 8.5%, P < .001).ConclusionsDelirium is a common OOH presentation, representing ~10% of consultations with patients ≥65 years. These patients often have cognitive impairment, require home visits and are more likely to be admitted to hospital. These findings are important for planning urgent care services tailored to the needs of older people.

ObjectiveTo summarise outcome domains and patient-reported outcome measures used in randomised controlled trials involving older adults with non-specific low back pain.MethodsSeven databases were searched from inception to January 2025. Two independent reviewers screened articles, extracted data and categorised patient-reported outcome measures into outcome domains using the Dodd et al. 38-item framework, where pain outcomes for non-specific pain are classified as ‘general outcome’, which we have relabelled as ‘pain’ for clarity. Frequencies of patient-reported outcome measure use and domain coverage were analysed. Adherence to core outcome set domains (physical functioning, pain and health-related quality of life) and core outcome measurement set for non-specific low back pain was evaluated.ResultsFrom 57 included trials, 74 patient-reported outcome measures were identified across nine outcome domains. Physical functioning (n = 80, 36%) and pain (n = 57, 26%) were the most frequently assessed. The most frequently used patient-reported outcome measures were the Roland–Morris Disability Questionnaire and the Visual Analogue Scale. Measures for physical functioning, pain and health-related quality of life were used in 91%, 86% and 23% of studies, respectively. Only 14% addressed all three-core outcome set domains; none adhered fully to the core outcome measurement set.ConclusionsTrials involving older adults with non-specific low back pain mainly evaluated pain and physical functioning, with limited coverage of other patient-centred domains. Future research should prioritise: (i) standardising outcome measurement with valid, reliable and responsive instruments; and (ii) developing and validating comprehensive, multi-domain outcome measures.

IntroductionOnly 6% of UK memory services meet Alzheimer’s disease (AD) biomarker access guidelines, limiting psychiatrists’ experience. Emerging AD blood biomarker (BBM) tests will potentially expand access. Exploring implementation barriers and enablers a priori can inform rollout strategies. This study examined current clinical practises, barriers and enablers to implementation and potential interventions to support implementation.MethodsIn November 2024, Royal College of Psychiatrists Old Age Psychiatry Faculty members (n = 172) participated in an online survey and four focus groups (n = 16 participants), informed by the Theoretical Domains Framework (TDF) and Behaviour Change Wheel. Demographic data were summarised descriptively. Mean (SD) belief statement scores for TDF domains and percentage agreement were calculated. Multiple linear regression examined associations between TDF domains and intention to use BBMs.ResultsRespondents were mainly consultants in England; <33% had used biomarkers. Key barriers to use were: ‘Knowledge,’ ‘Environmental Context and Resources’ and ‘Goals.’ Enablers included: ‘Behavioural Regulation,’ ‘Social Influences’ and ‘Intention.’ Mixed enablers/barriers included: ‘Beliefs about Consequences’, ‘Optimism’ and ‘Social/Professional Role & Identity’. In regression analyses, ‘Memory, Attention and Decision Processes’ (B = 0.44, 95%CI 0.20–0.68), ‘Beliefs about Consequences’(B = 0.45, 95%CI 0.11–0.78), and ‘Social Influences’ (B = 0.24, 95%CI 0.04–0.44) were positively associated with intention, while ‘Optimism’ (B = -0.31,95% CI-0.58 to-0.04) and ‘Emotion’ (B = -0.33, 95%CI -0.60 to-0.06) were negatively associated. Key interventions were ‘Guidelines’ (e.g. appropriate use criteria) and ‘Environmental Restructuring’ to expand resources and re-organise pathways.DiscussionA complex interplay of barriers and enablers influences AD BBM implementation. Interventions targeting clinician, service and policy levels are required to support their introduction.

Lower respiratory tract infections (LRTIs) are common among older adults and are associated with high healthcare utilization, particularly in those with multimorbidity (≥2 chronic conditions). We aimed to investigate the association between different multimorbidity patterns and LRTI-related hospitalizations. We used data from the population-based Swedish National study on Aging and Care in Kungsholmen (SNAC-K). Latent class analysis was applied to participants with multimorbidity to identify multimorbidity patterns. A disease was considered to characterize a pattern if exclusivity was ≥25% or the observed/expected ratio was ≥2. Cox regressions were used to estimate hazard ratios (HRs) for the association between multimorbidity patterns and [1] LRTI-related hospitalizations and [2] all-cause 30-day readmission, compared with participants without multimorbidity. Among the 3301 study participants, 2931 (87.5%) had multimorbidity, and over a median follow-up of 14years, 412 (12.5%) were hospitalized with an LRTI and 152 (4.5%) experienced a 30-day readmission. Five multimorbidity patterns were identified. The cardiometabolic pattern showed the highest hazards for LRTI-related hospitalizations and 30-day readmissions, followed by the psychiatric/respiratory pattern. The neuropsychiatric pattern was associated with increased hazard of 30-day readmissions. Multimorbidity patterns are differentially associated with LRTI-related hospitalizations and 30-day readmissions, suggesting that the link between LRTIs and multimorbidity patterns is complex and reflects the specific burden of diverse multimorbidity patterns.

BackgroundBrain imaging markers may help detect early cognitive decline and Alzheimer’s disease (AD). Although exercise-related effects on AD-specific brain signatures remain unclear.ObjectiveTo examine the effects of a 24-week resistance exercise (RE) program on AD brain signatures in cognitively unimpaired older adults, to explore potential moderators and to assess associations with cognition, including mediation effects.MethodsThis secondary analysis of a single-site, two-arm, single-blinded randomized controlled trial included 90 participants (72 ± 4 years; 58% female) randomly assigned by a blind external researcher to an RE group (3 sessions/week, 60 min/session, n = 46) or a wait-list control group (CG, n = 44). T1- and diffusion-weighted MRI were acquired at baseline and post-intervention. Primary outcomes were thickness/volume and grey matter mean diffusivity (GMMD) signatures, derived from cortical and hippocampal regions. Moderators included age, sex, education, multimorbidity, apolipoprotein E ϵ4 status, amyloid beta (Aβ) status and baseline AD brain signatures. Secondary outcomes included cognitive function. Outcome measures and analyses were conducted by staff blinded to intervention assignment.ResultsCompared with the CG, the RE group showed a reduction in the thickness/volume signature (−0.23 standardized mean difference [SMD]; 95% CI, −0.43 to −0.02), but no effect on the GMMD signature (0.08 SMD; 95% CI, −0.13 to 0.29). Aβ-status moderated the effect, as Aβ-positive participants in the RE group showed a larger reduction in the thickness/volume signature than those in the CG (−0.64 SMD; 95% CI, −1.09 to −0.18), whereas no effect was observed in Aβ-negative participants. Thickness/volume and GMMD reductions were associated with improvements in executive function and attentional/inhibitory control, respectively. Changes in AD signatures did not mediate cognitive outcomes.ConclusionOur findings suggest that reductions in the macrostructural AD signature following a 24-week RE program may reflect adaptive, rather than detrimental, brain changes, particularly in Aβ-positive older adults, as these changes were associated with improved executive function.Trial registrationRegistered on Clinicaltrials.gov (Identifier: NCT05186090).

Delirium is common in hospitalised older adults and is associated with mortality. Whether this prognostic association varies by baseline cognition is uncertain. We evaluated the association between delirium and 90-day mortality and whether baseline cognitive status modified this relationship. We conducted a prospective, multicentre cohort study of adults aged ≥65years admitted to 43 hospitals in five countries (Brazil, Angola, Chile, Colombia and Portugal; June2022-December2023). Delirium was assessed using the Confusion Assessment Method; cognitive status was measured using an informant-based Clinical Dementia Rating (CDR). Mortality within 90days of admission was ascertained from hospital records, structured telephone follow-up by blinded assessors and registry linkage. We used mixed-effects survival models with random intercepts (state/province and study centre) and sequential adjustment for sociodemographic, clinical and hospital-related factors. Effect modification by CDR was examined with stratified analyses. Among 2556 patients (mean age 79 ± 9years; 56% women), delirium occurred in 957 (37%). Delirium frequency rose with worsening cognition (CDR0: 16%; CDR0.5: 27%; CDR1: 59%; CDR2-3: 77%; P < .001). Delirium was associated with higher 90-day mortality (adjusted HR = 3.45; 95% CI = 2.83-4.20). The relative association with mortality was greatest in no dementia and attenuated in moderate-severe dementia. At 90days, cumulative mortality was 54% with delirium vs. 15% without in CDR0 (HR = 4.40; 95% CI = 3.15-6.16) and 36% vs. 17% in CDR2-3 (HR = 2.22; 95% CI = 1.34-3.66). Patients with delirium also experienced more in-hospital complications (nosocomial infection, functional decline and prolonged stay). Although delirium was more frequent among patients with dementia, its relative association with 90-day mortality was strongest in those with no baseline dementia. The results provide a strong rationale for intervention trials to determine whether delirium prevention and management strategies can reduce mortality, particularly among patients without known dementia.

Goals of care discussions (GOCDs) are critical for patients with serious illnesses but are hindered by clinician-level barriers. Nudges-low-burden, behaviourally informed strategies that influence clinician behaviour without restricting choice-may provide a scalable approach to increase GOCDs. We systematically reviewed and meta-analysed the effect of clinician-directed nudges on GOCD documentation. Secondary outcomes were quality of communication and healthcare utilisation. We searched three databases (2004-2024). Nudges were classified using the MINDSPACE framework. Random-effects meta-analysis estimated pooled odds ratios (ORs) with 95% confidence intervals (CIs) for GOCD documentation. Subgroup analyses examined nudge type, study design and co-interventions. Secondary outcomes were narratively synthesised. Fifty-one studies were included (16 randomised trials, 7 non-randomised controlled studies and 28 pre-post studies). Salience-based nudges, which make key information more noticeable, were most common (86% of interventions). Most interventions (87%) were multicomponent. Nudges increased GOCD documentation (OR 3.30, 95% CI 2.40-4.53). Multicomponent interventions with a nudge component had larger effects than nudges alone (OR 4.03 vs. 1.89; P = .03). No differences were observed by nudge types or study designs. Heterogeneity was high (I2= 96.7%) but leave-one-out sensitivity analyses supported robustness. Nudges improved quality of communication (2/2 studies) and reduced readmissions (2/2), with inconsistent effects on palliative care referrals (5/19) and no impact on hospital length of stay (0/5). Clinician-directed nudges improve GOCD documentation and represent a scalable, low-cost strategy for quality improvement. Future research should examine a broader range of nudges, multilevel interventions and effects on the quality and timing of GOCDs across settings.

The prognostic relevance of perioperative myocardial injury/infarction (PMI) in older patients undergoing major noncardiac surgery remains unclear, as high comorbidity burden may lessen its impact. Older patients (defined as age ≥70years with ≥3 comorbidities, or ≥80years) enrolled in a multicentre, prospective study of patients at increased cardiovascular risk undergoing major noncardiac surgery were analysed. The primary endpoint, all-cause mortality at 1year, was analysed using Cox proportional hazards regression. Secondary endpoints included major adverse cardiac events (MACE) (cardiovascular death, acute myocardial infarction, life-threatening arrhythmia and acute heart failure), analysed using Fine-Grey hazard regression. All models were adjusted for prespecified confounders with PMI as a time-varying exposure. Amongst 4634 older patients (median age 80years; 42.9% women), PMI occurred in 892 patients (19.2%), which was higher than in younger patients (P < .0001). The distribution of PMI aetiologies was comparable between groups. At 1year, all-cause mortality was 26.2% in patients with PMI and 13.2% in patients without PMI, and MACE occurred in 30% versus 13%, respectively. After multivariable adjustment, the hazard ratio of PMI was highest on postoperative day 1 (all-cause mortality: 10.5 [95% CI 4.5-24.5]; MACE: 4.4 [95% CI 3.2-5.9]), declined by day 90 (1.4 [95% CI 1.0-1.9] and 2.2 [95% CI 1.7-2.7], respectively), and persisted through 1year. PMI was very common amongst older patients and associated with substantially higher 1-year risks of all-cause mortality and MACE, with greatest vulnerability observed during the initial 90 postoperative days.