Objectives: Health outcomes among older emergency department (ED) patients may be influenced by physical, economic, and psychological problems not routinely identified during the ED visit. The objective of this study was to characterize such problems among older adults presenting to the ED.Methods: This was a prevalence study with enrollment during 4-hour periods randomly selected between 9 a.m. and 9 p.m. on random days of the week over a period of 8 weeks at an academic ED in the southeast United States. Participants were noninstitutionalized, cognitively intact adults aged 65 years or older without life-threatening illness or injury. Consenting patients were asked about the frequency of 10 prespecified problems during the past year.Results: Patients (N = 138) were non-Hispanic white (69%) and female (57%) and almost all had primary providers (95%) and health insurance (98%). Forty percent reported their overall health as fair (21%) or poor (19%). Hazardous drinking habits were reported by 10% of patients. The prevalence of problems occurring either "sometimes" or "often" in the past year were pain (60%), difficulty walking (47%), lack of money (32%), isolation and loneliness (14%), lack of transportation (12%), difficulty scheduling a doctor's appointment (4%), difficulty getting prescriptions filled (4%), and lack of dental care (6%). Nine patients (7%) reported experiencing physical or psychological abuse at some point in the past year. Females, minorities, and individuals living in urban areas reported higher rates of most problems.Conclusions: Nonmedical problems are common among cognitively intact, independent living, noncritically ill older patients presenting to an ED in the southeast United States.ACADEMIC EMERGENCY MEDICINE 2014;21:651-658

Twitter: @clshenvi.Agitation and delirium are common reasons for older adults to seek care in the emergency department (ED). Providing care for this population in the ED setting can be challenging for emergency physicians. There are several knowledge translation gaps in how to best screen older adults for these conditions and how to manage them. A working group of subject-matter experts convened to develop an easy-to-use, point-of-care tool to assist emergency physicians in the care of these patients. The tool is designed to serve as a resource to address the knowledge translation and implementation gaps that exist in the field. The purpose of this article is present and explain the Assess, Diagnose, Evaluate, Prevent, and Treat tool. Participants were identified with expertise in emergency medicine, geriatric emergency medicine, geriatrics, and psychiatry. Background literature reviews were performed before the inperson meeting in key areas: delirium, dementia, and agitation in older adults. Participants worked electronically before and after an in-person meeting to finalize development of the tool in 2017. Subsequent work was performed electronically in the following months and additional expert review sought. EDs are an important point of care for older adults. Behavioral changes in older adults can be a manifestation of underlying medical problems, mental health concerns, medication adverse effects, substance abuse, or dementia. Five core principles were identified by the group that can help ensure adequate and thorough care for older adults with agitation or delirium: assess, diagnose, evaluate, prevent, and treat. This article provides background for and explains the importance of these principles related to the care of older adults with agitation. It is important for emergency physicians to recognize the spectrum of underlying causes of behavioral changes and have the tools to screen older adults for those causes, and methods to treat the underlying causes and ameliorate their symptoms.

In 2018, the American College of Emergency Physicians began accrediting facilities as "Geriatric Emergency Departments" (GEDs) based on adherence to the multi-organizational guidelines published in 2014. The guidelines were developed in order to help every emergency department (ED) improve its care of older adults. The GED guideline recommendations span the care continuum from pre-hospital care, ED staffing, protocols, infrastructure, and transitions to outpatient care. Hospitals interested in making their EDs more geriatric-friendly thus face the challenge of adopting, adapting, and implementing extensive guideline recommendations in a cost-

Protein biosynthesis requires numerous conformational rearrangements within the ribosome. The structural core of the ribosome is composed of RNA and is therefore dependent on counterions such as magnesium ions for function. Many steps of translation can be compromised or inhibited if the concentration of Mg 2+ is too low or too high. Conditions previously used to probe the conformation of the mammalian ribosome in vitro used high Mg 2+ concentrations that we find completely inhibit translation in vitro. We have therefore probed the conformation of the small ribosomal subunit in low concentrations of Mg 2+ that support translation in vitro and compared it with the conformation of the 40S subunit at high Mg 2+ concentrations. In low Mg 2+ concentrations, we find significantly more changes in chemical probe accessibility in the 40S subunit due to subunit association or binding of the hepatitis C internal ribosomal entry site (HCV IRES) than had been observed before. These results suggest that the ribosome is more dynamic in its functional state than previously appreciated.

During apoptosis and under conditions of cellular stress, several signaling pathways promote inhibition of cap-dependent translation while allowing continued translation of specific messenger RNAs encoding regulatory and stress-response proteins. We report here that the apoptotic regulator Reaper inhibits protein synthesis by binding directly to the 40S ribosomal subunit. This interaction does not affect either ribosomal association of initiation factors or formation of 43S or 48S complexes. Rather, it interferes with late initiation events upstream of 60S subunit joining, apparently modulating start-codon recognition during scanning. CrPV IRES-driven translation, involving direct ribosomal recruitment to the start site, is relatively insensitive to Reaper. Thus, Reaper is the first known cellular ribosomal binding factor with the potential to allow selective translation of mRNAs initiating at alternative start codons or from certain IRES elements. This function of Reaper may modulate gene expression programs to affect cell fate.Rapid changes in cellular gene expression are often brought about by regulation at the level of protein synthesis from existing mRNA transcripts. Such alterations are particularly important under conditions of cellular stress and apoptosis, and during certain stages of mitosis 1 . Cellular stresses such as viral infection or nutrient deprivation lead to an almost immediate shutdown of general translation accompanied by cleavage or covalent modification of one or more of the eukaryotic initiation factors (eIFs) 2-5 . However, this attenuation of translation is typically accompanied by a selective increase in the translation of specific regulatory proteins 6-9 whose sustained expression can affect cell fate 1,10 . How particular mRNAs are selectively translated during periods of global translation inhibition is not well understood.