Delirium is a neuropsychiatric diagnosis that is very common in general medical and surgical populations but of particular importance in palliative medicine. The incidence is twice that of a regular nursing floor averaging 30%. At end-of-life the percentage may be as high as 88%.Several different pathophysiologies have been investigated to define the underlying mechanisms to enable targeted therapy. The most commonly accepted cause is a decrease in acetylcholine and increased dopamine.

Presentation:

Delirium is a syndrome with myriad presentation usually divided into motoric subtypes -hypoactive, hyperactive and mixed. It is underdiagnosed particularly the hypoactive subgroup which may be more common in the palliative medicine population and may be confused with depression. Medications are the most common causes and unfortunately, the majority of medications used in palliative medicine have the potential to cause delirium.

Major Depression is common in late life.  It not only causes suffering but it contributes to disability aggravates the course of medical illness and increases mortality.  Both psychotherapy and antidepressants are effective in late life depression.  In a systematic review of older depressed adults we found 27 trials of psychotherapy with 37 comparisons and 2,245 subjects. Psychotherapy was more effective than the control condition but the effect size varied greatly with the type of control.  Trials with waitlist controls showed a large effect size while those with a supportive therapy control had a smaller effect similar to that of antidepressant treatment.  Problem Solving Therapy had the best evidence for efficacy.  We conducted a systematic review of second generation antidepressants in community dwelling adults 60 years and older with Major Depression. 10 trials with 4,165 subjects demonstrated antidepressants were more effective than placebo but the effect size was small resulting in a number-needed-to-treat of 11.  We were able to obtain individual patient data from the sponsors of each of the 10 studies with which we performed a patient level analysis of moderators of antidepressant response. Interestingly age was not a significant moderator. The primary moderator was the lifetime duration of Major Depression. The longer the duration, the lower the placebo response and the greater the drug placebo difference. The finding was replicated in a mixed age sample.

Geriatric  cancer patients  are vulnerable to  any  disturbance in careful healthcare provision. For example, in Poland, still reforming its oncological care, mortality due to breast cancer raised abruptly in eldest female +85  from 2014 despite the incidence had risen in closely preceding years mainly in younger females, most rapidly in  65-69 age group (1). Also, we have observed that not only undertreatment of elder breast cancer patients may influence survival  (2). We postulate that geriatric cancer patients need, a not mainly standardized protocols for different modalities of concomitant treatment but also tailored and coordinated social and medical support. COVID-19 pandemic apparently interfered with healthcare performance. In early series of patients with hematologic malignancies and COVID-19, mortality was associated with higher age, more comorbidities, type of hematological malignancy and type of antineoplastic therapy (3). Mainly patients ≥60 with hematologic malignancy and COVID-19 had a high risk of dying, while pediatric patients were relatively spared and It was concluded that recent cancer treatment does not appear to significantly increased the risk of death.

Causes of diabetic foot wound are multiple factors including peripheral neuropathy, decreased blood supply, high plantar pressures. Elderly diabetic foot wound may be a significant risk for morbidity, limb amputation and mortality. There is no conventional guideline regarding the selection of wound care materials in elderly diabetic foot wounds. According to the colors of the diabetic foot wound (Red-Yellow-Black wound) , it may classified in four categories.  Also, grading can be done using Wagner’s or the Texas wound classification system. Anyway, the foot is a complex structure, which acts as a foundation for the whole body, and it is important to prevent progression of diabetic foot problems. Therefore the some specialists play an important role in wound management of diabetic foot including endocrinologist, podiatrist, vascular surgeon, microbiologist, orthoptist, and nutritionist. Choice of wound care in elderly diabetic foot wounds may be based on wound healing process, patient status, and anatomical changes in foot. Revascularization, debridement, offloading, antibiotic therapy, and wound care by using dressing. There are more products which help to cleaning of the wound, improve tissue granulation and wound healing. Some of them are Polyurethane films, Polyurethane foam, Hydrogel dressings, Alginate dressings, Growth factors, Honey-impregnated dressing, Topical enzymes and also Mechanical device such as Vacuum-assisted closure which generates a topical negative pressure over the wound bed. The successful management of elderly diabetic foot wounds requires the multidisciplinary teamwork of specialists. There are various topical regimes available, but the choice depends only on the treating physicians, podiatrist, or clinical care nurse.