ObjectivesWe aimed to determine age-specific rates of delirium and associated factors in acute medicine, and the impact of delirium on mortality and re-admission on long-term follow-up.DesignObservational study. Consecutive patients over two 8-week periods (2010, 2012) were screened for delirium on admission, using the confusion assessment method (CAM), and reviewed daily thereafter. Delirium diagnosis was made using the Diagnostic and Statistical Manual Fourth Edition (DSM IV) criteria. For patients aged ≥65 years, potentially important covariables identified in previous studies were collected with follow-up for death and re-admission until January 2014.Participants503 consecutive patients (age median=72, range 16–99 years, 236 (48%) male).SettingAcute general medicine.ResultsDelirium occurred in 101/503 (20%) (71 on admission, 30 during admission, 17 both), with risk increasing from 3% (6/195) at <65 years to 14% (10/74) for 65–74 years and 36% (85/234) at ≥75 years (p<0.0001). Among 308 patients aged >65 years, after adjustment for age, delirium was associated with previous falls (OR=2.47, 95% CI 1.45 to 4.22, p=0.001), prior dementia (2.08, 1.10 to 3.93, p=0.024), dependency (2.58, 1.48 to 4.48, p=0.001), low cognitive score (5.00, 2.50 to 9.99, p<0.0001), dehydration (3.53, 1.91 to 6.53, p<0.0001), severe illness (1.98, 1.17 to 3.38, p=0.011), pressure sore risk (5.56, 2.60 to 11.88, p<0.0001) and infection (4.88, 2.85 to 8.36, p<0.0001). Patients with delirium were more likely to fall (OR=4.55, 1.47 to 14.05, p=0.008), be incontinent of urine (3.76, 2.15 to 6.58, p<0.0001) or faeces (3.49, 1.81–6.73, p=0.0002) and be catheterised (5.08, 2.44 to 10.54, p<0.0001); and delirium was associated with stay >7 days (2.82, 1.68 to 4.75, p<0.0001), death (4.56, 1.71 to 12.17, p=0.003) and an increase in dependency among survivors (2.56, 1.37 to 4.76, p=0.003) with excess mortality still evident at 2-year follow-up. Patients with delirium had fewer re-admissions within 30-days (OR=0.32, 95% CI 0.09 to 1.1, p=0.07) and in total (median, IQR total re-admissions=0, 0–1 vs 1, 0–2, p=0.01).ConclusionsDelirium affected a fifth of acute medical admissions and a third of those aged ≥75 years, and was associated with increased mortality, institutionalisation and dependency, but not with increased risk of re-admission on follow-up.

In this article, we review key factors in promoting a culturally diverse and inclusive learning environment for all undergraduate medical students, and the role of primary care educators in preparing students to work with diverse teams, patients and communities. These factors include approaches to curriculum and assessment, student community, faculty development and recruitment, and wider institutional factors. By highlighting these, including areas where further research, evaluation and consensus are needed, we hope to support further discourse on how primary care educators can promote culturally diverse and inclusive undergraduate medical education.

This article explores how the concept of vertical leadership development might help health organizations cope with and thrive within highly complex and unpredictable health systems, looking at concepts of VUCA (volatility, uncertainty, complexity and ambiguity) and RUPT (rapid, unpredictable, paradoxical and tangled).

Background: Dapagliflozin is the first sodium-glucose cotransporter 2 (SGLT2) inhibitor to be approved in Europe and represents a new class of agents developed as oral diabetes medications. Improved glycaemic control and weight loss have been demonstrated in clinical trials but effectiveness outside of the trial environment has not yet been reported. Method: A systematic clinical case note audit of type 2 diabetes patients initiated on dapagliflozin in a diabetes specialist outpatient centre of a London teaching hospital. Results: Of the 96 people included, 42% had a reduction in glycated haemoglobin (HbA1c) of >1%, 29% had no reduction; 15% had weight loss >5kg, 3% had weight loss >10kg and 24% had no weight reduction. Improvements in HbA1c, weight, and blood pressure were consistent with those reported in clinical trials. The rate of discontinuation of dapagliflozin due to side effects (22%) was higher than reported in trials (3-4%), but 52% of people tolerating dapagliflozin were able to stop or reduce one or more other diabetes medications. Conclusions: Dapagliflozin is effective at improving glycaemic control. It also reduces blood pressure, results in weight loss, and reduces the need for concomitant diabetes medications. However, it is not as well tolerated in real-world patients as in participants of clinical trials.

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