Our study underscores the strong association between presence of a DNR order and mortality. Further studies are necessary to better understand the presence and timing of DNR orders in hospitalized older adults.

Background/Objectives Whereas opiate prescribing patterns have been well described in outpatient and emergency department settings, they have been less defined in hospitalized older adults. The objective was to describe patterns of opiate prescribing and associated outcomes in hospitalized older adults. Design Retrospective cohort study. Setting Tertiary care facility. Participants Hospitalized medical patients aged 65 and older (N = 9,245; mean age 80.3, 55.2% female, 72.3% white, 90.8% non‐Hispanic). Measurements Opiate exposure and duration of action, concurrent use of potentially inappropriate medications (PIMs), adverse events, discharge disposition, length of stay (LOS), and 30‐day readmissions. Results There was no difference in sex, race, ethnicity, or Charlson Comorbidity Index between opiate exposure groups. Participants who had never received opiates had a significantly shorter mean LOS than prior and new opiate users (5.2, 6.8, 7.7 days; P < .001) and were more likely to be discharged home (88.6%, 82.8%, 82.5%; P < .001) and significantly less likely to be readmitted within 30‐days (19.6%, 25.0%, 22.3%; P < .001). Participant who had never been exposed to opiates had a significantly shorter mean LOS than those receiving short‐ and long‐acting opiates (5.2, 7.3, 8.6 days; P < .001) and were more likely to be discharged home (88.6%, 82.6%, 82.4%; P < .001) and significantly less likely to be readmitted within 30‐days (19.6%, 27.7%, 28.9%; P < .001). Conclusion Opiate use is widespread during hospitalization and is associated with significant negative clinical outcomes and quality metrics. There is an urgent need to develop innovative pain management alternatives to opiate use.

Background: Delirium is one of the most common, costly, and devastating complications affecting up to 56% of hospitalized older patients, with an associated hospital mortality rate of 25%–33%, and annual health care expenditures exceeding $152 billion. Areas of Uncertainty: Despite its high prevalence and poor outcomes, there is a significant gap in therapeutic interventions for the prevention and treatment of delirium. Therapeutic Interventions: Nonpharmacologic multicomponent prevention interventions such as the hospital elder life program (HELP) and early mobilization and reorientation remain first line, and they have consistently demonstrated a reduction in the incidence of delirium. There is currently no evidence to support the use of antipsychotics, cholinesterase inhibitors, or psychostimulants for the prevention of delirium across all health care settings, including the intensive care unit. Avoiding sedation, and specifically benzodiazepines, is an important modality to prevent delirium. Given the lack of evidence to support the use of antipsychotics along with the adverse event profile, including a black box warning for an increase in cardiovascular mortality, these medications should only be used for the treatment of delirium with features of severe agitation and psychosis. In the intensive care unit setting, dexmedetomidine in lieu of propofol or other classic sedatives may prevent and shorten the duration of delirium. Finally, dexmedetomidine and general anesthetics, such as sevoflurane and desflurane, are being evaluated in the prevention and treatment of postoperative delirium. Conclusion: Multicomponent nonpharmacologic interventions are currently the most effective modality for the prevention and treatment of delirium.