Background Among asymptomatic patients with severe carotid artery stenosis but no recent stroke or transient cerebral ischaemia, either carotid artery stenting (CAS) or carotid endarterectomy (CEA) can restore patency and reduce long-term stroke risks. However, from recent national registry data, each option causes about 1% procedural risk of disabling stroke or death. Comparison of their long-term protective effects requires large-scale randomised evidence.Methods ACST-2 is an international multicentre randomised trial of CAS versus CEA among asymptomatic patients with severe stenosis thought to require intervention, interpreted with all other relevant trials. Patients were eligible if they had severe unilateral or bilateral carotid artery stenosis and both doctor and patient agreed that a carotid procedure should be undertaken, but they were substantially uncertain which one to choose. Patients were randomly allocated to CAS or CEA and followed up at 1 month and then annually, for a mean 5 years. Procedural events were those within 30 days of the intervention. Intention-to-treat analyses are provided. Analyses including procedural hazards use tabular methods. Analyses and meta-analyses of non-procedural strokes use Kaplan-Meier and log-rank methods. The trial is registered with the ISRCTN registry, ISRCTN21144362.

SummaryMaintaining patient safety in acute hospitals is a global health challenge. Traditionally, patient safety measures have been concentrated on critical care and surgical patients. In this review the medical literature was reviewed over the last ten years on aspects of patient safety specifically related to patients with dementia. Patients with dementia do badly in hospital with frequent adverse events resulting in the geriatric syndromes of falls, delirium and loss of function with increased length of stay and increased mortality. Contributory factors include inadequate assessment and treatment, inappropriate intervention, discrimination, low staff levels and lack of staff training. Unfortunately there is no one simple solution to this problem, but what is needed is a multifactorial, multilevel approach at the seven levels of care -patient, task, staff, team, environment, organisation and institution.Improving safety and quality of care for patients with dementia in acute hospitals will benefit all patients and is an urgent priority for the NHS.

-Delirium (acute confusional state) is a common condition in older people, affecting up to 30% of all older patients admitted to hospital. Patients who develop delirium have high mortality, institutionalisation and complication rates, and have longer lengths of stay than non-delirious patients. Delirium is often not recognised by clinicians, and is often poorly managed. Delirium may be prevented in up to a third of older patients. The aim of this guideline update is to aid prevention as well as the recognition of delirium and to provide guidance on how to manage these complex and disadvantaged patients.KEY WORDS: acute confusion, clinical guideline, delirium, older people IntroductionThe aim of these guidelines is to aid recognition of delirium and to provide guidance on how to manage this complex and challenging condition. Delirium is characterised by a disturbance of consciousness and a change in cognition that develop over a short period of time. The disorder has a tendency to fluctuate during the course of the day, and there is evidence from the history, examination or investigations that the delirium is a direct consequence of a general medical condition, drug withdrawal or intoxication. Diagnostic and Statistical Manual of Mental Disorders (DSM IV) 1In order to be diagnosed with delirium, a patient must show all of the four features listed below. 1 A disturbance of consciousness (ie reduced clarity of awareness of the environment) is evident, with reduced ability to focus, sustain or shift attention. 2 There is a change in cognition (such as memory deficit, disorientation, language disturbance) or the development of a perceptual disturbance that is not better accounted for by a preexisting or evolving dementia. 3 The disturbance develops over a short period of time (usually hours to days) and tends to fluctuate during the course of the day. 4 There is evidence from the history, physical examination, or laboratory findings that the disturbance is caused by the direct physiological consequences of a general medical condition, substance intoxication or substance withdrawal. 1 Delirium may have more than one causal factor (ie multiple aetiologies). A diagnosis of delirium can also be made when there is insufficient evidence to support criterion 4, if the clinical presentation is consistent with delirium, and the clinical features cannot be attributed to any other diagnosis, for example delirium due to sensory deprivation.Some older people come to hospital with delirium (prevalent) while others develop delirium during their hospital stay (incident). Hospital prevalence rates for delirium vary widely because of different patient characteristics in the different studies -the highest rates are seen in older patients in critical care settings. The average prevalence of delirium in older people in general hospitals is 20% (range 7% to 61%). 2 After fracture of the neck of the femur, the prevalence varies from 10% to 50%.Patients with delirium have increased length of stay, increased mortality and increased ...

A random sample of 140 elderly people aged over 75 was selected from the age-sex register of an urban general practice to assess the provision and use of aids and adaptations in their homes. Many ofthe aids that the elderly had were faulty, including half of the walking aids and 15% of hearing aids, reading spectacles, and dentures, and up to halfofthe aids were not used. Yet despite this underuse there were many disabled elderly people who required aids for the bath and toilet.

Joint geriatric/psychiatric wards are a potential solution to improving care of older patients with both psychiatric and medical illnesses in acute hospitals. A literature search using Medline, PsycINFO, Embase and CINAHL between 1980 and 2010 was carried out for information about joint wards for older people. Thirteen relevant papers were identified. These wards share common characteristics and there is evidence that they may reduce length of stay and be cost-effective, but there are no high-quality randomised controlled trials. Further research is needed, particularly regarding cost-effectiveness.