Frailty predicts failure to discharge patients home from a subacute-care unit: a 3-year Italian experience.

BACKGROUND: The primary purpose of Subacute Care Units (SCU) is to decongest acute hospital wards and facilitate the return of older patients to home. AIMS: We analyzed the clinical characteristics and outcomes of patients admitted to an Italian SCU, and we explored factors associated with discharge to locations other than home (outcome). METHODS: This retrospective observational cohort study was conducted at a medium-sized suburban hospital, enrolling all patients consecutively admitted to one SCU from October 2017 to February 2020. We collected demographics, cause of admission, comorbidities, cognition, Barthel Index (BI), nutritional status, Clinical Frailty Scale (CFS), length of stay, and discharge destination. Delirium was screened with the 4AT score. We adopted a multivariable conditional logistic regression model to identify the factors associated with the outcome. RESULTS: Frail subjects accounted for 58.6% of 406 patients (mean age 78.2 years, SD 11.6), while 61% were classified as functionally dependent. More than half of patients had relevant comorbidity, approximately 80% had a poor nutritional status, and 25% had pre-existing dementia. The overall prevalence of delirium was 14.5%. Most patients came from a hospital setting; recurrent reasons for admission were infections (70.5%) and heart failure (12.7%). Having a urinary bladder catheter at discharge, being overtly frail (CFS > 8), and low BI score were factors independently associated with not being discharged home. DISCUSSION AND CONCLUSION: The routine assessment of frailty, as expressed by the CFS, may help redirecting the patients eligible for SCU admission.

Prevalence, clinical correlates, and burden of undiagnosed aortic stenosis in older patients: a prospective study in a non-cardiologic acute hospital ward.

BACKGROUND: The epidemiology of aortic stenosis (AS) in older patients admitted to non-cardiologic acute hospital wards and the effect of AS on mid-term survival are incompletely reported. In a cohort of very old patients admitted to an acute geriatric unit (AGU), we aimed to assess: (1) the prevalence of newly and previously diagnosed AS; and (2) the association between AS severity and patients' 6-month mortality. METHODS: The patients consecutively admitted in two AGU rooms from February 2016 to February 2018 were assessed with echocardiography and AS severity was defined according to standard criteria. We assessed frailty using a 34-item Frailty Index (34-FI), which was operationalized using health variable information, and the Clinical Frailty Scale (CFS). Vital status at 6 months was extracted from Regional Register of Birth and Death. RESULTS: Two hundred and three patients (mean age 84.5 ± 6.0 SD, female gender 56.1%) were included. Of these, 57 (28.1%) had AS, mild in 9 (4.5%), moderate in 32 (16.1%) and severe in 16 (8.1%). A new diagnosis of AS was obtained in 42 (73.7%) patients, of whom 33 (78.6%) had moderate or severe AS. At 6 months, 61 (28.9%) patients died. In multiple regression models, after adjusting for covariates, frailty, as assessed with both FI and CFS, was independent predictor of 6-month mortality whereas AS was not. CONCLUSIONS: Among older patients admitted to non-cardiologic acute hospital wards, AS was common and frequently underdiagnosed. The severity of AS was not associated with increased 6-month mortality, whereas frailty was the most important predictor.

The relationship among frailty, delirium and attentional tests to detect delirium: a cohort study.

BACKGROUND: Few studies explored if frailty predisposes to delirium in hospitalized older patients. The aims of this study were to evaluate if frailty: 1) is independently associated with delirium, and 2) affects the patient's performance in three tests of attention used to detect delirium. METHODS: Data are from a prospective cohort study of patients admitted to an Acute Geriatric Unit (AGU). Frailty was operationalized using the health deficit accumulation model (38-item Frailty Index). Delirium was screened using the 4AT, and the diagnosis confirmed with the DSM-5th criteria. During the first 7 days from the hospital admission, patients also underwent a double-blind assessment of attention using three ad hoc tests (i.e., Months of the year backwards, MOTYB; Days of the week backwards, DOWB; and Count backwards from 20 to 1, CB). RESULTS: Eighty-nine patients were included (mean age 83.1 years, standard deviation 6.0). Forty-two (47.19%) patients were frail, and 37 (41.7%) had delirium. The likelihood of delirium was significantly higher in frail compared to the non-frail patients; it was also inversely associated with the three attention tests. Using the MOTYB test, the ability to discriminate delirium was similar in patients with (Area Under the Receiving Operator Characteristic [AUROC] 0.88, 95% Confidence Interval [CI] 0.82-0.92) and without frailty (AUROC 0.93, 95%CI 0.90-0.95) whilst was markedly different between the same groups using either DOWB and CB. CONCLUSIONS: Frailty is associated with delirium in hospitalized older patients and can influence the patient's performances at attentional tests that are commonly used to screen delirium.

Relation Between Delirium and Anticholinergic Drug Burden in a Cohort of Hospitalized Older Patients: An Observational Study.

BACKGROUND: Delirium is a neuropsychiatric syndrome which occurs on average in one out of five hospitalized older patients. It is associated with a number of negative outcomes, including worsening of cognitive and functional status, increasing the burden on patients and caregivers, and elevated mortality. Medications with anticholinergic effect have been associated with the clinical severity of delirium symptoms in older medical inpatients, but this association is still debated. OBJECTIVE: The aim was to assess the association between delirium and anticholinergic load according to the hypothesis that the cumulative anticholinergic burden increases the risk of delirium. METHODS: This retrospective, cross-sectional study was conducted in a sample of older patients admitted to the Acute Geriatric Unit (AGU) of the San Gerardo Hospital in Monza (Italy) between June 2014 and January 2015. Delirium was diagnosed on admission using the 4 'A's Test (4AT), a validated screening tool for delirium diagnosis, which has shown good sensitivity and specificity to detect this condition in elderly patients admitted to an AGU. Each patient's anticholinergic burden was measured with the Anticholinergic Cognitive Burden (ACB) scale, a ranking of anticholinergic medications to predict the risk of adverse effects on the central nervous system in older patients. RESULTS: Of the 477 eligible for the analysis, 151 (31.7%) had delirium. According to the ACB scale, 377 patients (79.0%) received at least one anticholinergic drug. Apart from quetiapine, which has a strong anticholinergic effect, the most commonly prescribed anticholinergic medications had potential anticholinergic effects but unknown clinically relevant cognitive effects according to the ACB scale (score 1). Patients with delirium had a higher anticholinergic burden than those without delirium, with a dose-effect relationship between total ACB score and delirium, which was significant at univariate analysis. A plateau risk was found in patients who scored 0-2, but patients who scored 3 or more had about three or six times the risk of delirium than those not taking anticholinergic drugs. The dose-response relationship was maintained in the multivariate model adjusted for age and sex [odds ratio (OR) 5.88, 95% confidence interval (CI) 2.10-16.60, p = 0.00007], while there was only a non-significant trend in the models adjusted also for dementia and Mini Nutritional Assessment (OR 2.73, 95% CI 0.85-8.77, p = 0.12). CONCLUSIONS: Anticholinergic drugs may influence the development of delirium due to the cumulative effect of multiple medications with modest antimuscarinic activity. However, this effect was no longer evident in multivariable logistic regression analysis, after adjustment for dementia and malnutrition. Larger, multicenter studies are required to clarify the complex relationship between drugs, anticholinergic burden and delirium in various categories of hospitalized older patients, including those with dementia and malnutrition.

A Rare Diagnosis After the Fall of a 96-Year-Old Woman: Doege-Potter Syndrome.

INTRODUCTION: Doege-Potter Syndrome (DPS) is a rare but life-threatening paraneoplastic syndrome, characterized by Non-Islet Cell Tumor-Induced Hypoglycemia (NICTH) secondary to a Solitary Fibrous Tumor (SFT), which secretes an incompletely processed form of Insulin-like Growth Factor 2 (IGF-2). RESULTS: A 96-year-old woman was admitted with head trauma due to an accidental fall. During her hospital stay she experienced frequent hypoglycemic episodes. Multiple injections of 33% dextrose and continuous infusion with 10% dextrose were required to maintain normal blood glucose levels. Biochemical analyses revealed hypoinsulinemic hypoglycemia, low C-peptide levels, suppressed insulin-like growth factor-1, normal insulin-like growth factor-2, and an elevated IGF-2:IGF-1 ratio, all consistent with IGF-2 secretion by a non-islet cell tumor. A contrast-enhanced chest and abdominal CT scans showed a single large pleural mass in the left lower hemithorax measuring 15x14 cm without secondary lesions. Histological analysis of biopsied specimens suggested a solitary fibrous pleural tumor; accordingly, a diagnosis of Doege-Potter syndrome was considered. Due to extensive tumor burden and the advanced age of the patient, supportive and non-invasive management was chosen. Dexamethasone therapy was started, and while receiving this therapy she was able to discontinue glucose infusion and successfully maintain euglycemia. DISCUSSION: In the elderly, a sudden and unexplained fall can be the expression of severe hypoglycemia, usually as a complication of insulin therapy or of oral hypoglycemic agents administered to patients with diabetes. However, in patients without diabetes, other causes should be investigated, and the hypothesis of neoplastic diseases should be considered. CONCLUSION: In this case report we describe an uncommon cause of paraneoplastic hypoglycemia occurring in the oldest patient with a non-islet cell tumor reported thus far.

Frailty and Delirium in Older Adults: A Systematic Review and Meta-Analysis of the Literature.

OBJECTIVES: To evaluate the relationship between frailty and delirium. DESIGN: Systematic review and meta-analysis. SETTING: MEDLINE, EMBASE, PubMed, Scopus, Web of Science, and Google Scholar databases were searched for articles on frailty and delirium published on or before October 31, 2017. PARTICIPANTS: Individuals aged 65 and older. MEASUREMENTS: Two authors independently reviewed all English-language citations, extracted relevant data, and assessed studies for potential bias. Articles involving pediatric or neurosurgical populations, alcohol or substance abuse, psychiatric illness, head trauma, or stroke, as well as review articles, letters, and case reports were excluded. Studies underwent qualitative or quantitative analysis according to specified criteria. Using a random-effects or fixed-effects model, relative risk (RR) was calculated for the effect of frailty as a predictor of subsequent delirium. Heterogeneity was tested using Q and I2 statistics. RESULTS: We identified 1,626 articles from our initial search, of which 20 fulfilled the selection criteria (N=5,541 participants, mean age 77.8). Eight studies were eligible for meta-analysis, showing a significant association between Q2 frailty and subsequent delirium (RR = 2.19, 95% confidence interval = 1.65-2.91). There was low variability among studies in the measures of association between frailty and delirium (I2 2.24, p-value Q-statistic = .41) but high heterogeneity in the methods used to assess the two conditions. CONCLUSION: This systematic review and meta-analysis supports the existence of an independent relationship between frailty and delirium, although there is notable methodological heterogeneity between the methods used to assess the 2 conditions. Future studies are needed to better delineate the dynamics between these syndromes.

The impact of psychomotor subtypes and duration of delirium on 6-month mortality in hip-fractured elderly patients.

OBJECTIVE: Studies exploring the incidence and impact of the psychomotor subtypes of postoperative delirium (POD) on the survival of hip fracture patients are few, and results are inconsistent. We sought to assess the incidence of POD subtypes and their impact, in addition to delirium duration, on 6-month mortality in older patients after hip-fracture surgery. METHODS: This is a prospective study involving 571 individuals admitted to an Orthogeriatric Unit within a 5-year period with a diagnosis of hip fracture. Survival status was assessed 6 months after posthip fracture surgery. Postoperative delirium was diagnosed using the Diagnostic and Statistical Manual of Mental Disorders. Postoperative delirium subtypes were classified according to Lipowski's criteria. Cox regressions were used to evaluate the associations between POD subtypes, POD duration, and 6-month mortality, adjusting for covariates. RESULTS: The incidence of psychomotor POD subtypes was hypoactive 57 (10.0%), hyperactive 84 (14.7%), and mixed 79 (13.8%). Six-month mortality rates were 8.3%, 10.7%, 36.8%, and 29.1% in the no-delirium, hyperactive, hypoactive, and mixed-delirium subgroups, respectively. In adjusted models, the hypoactive subgroup (Hazard Ratio, HR = 3.14, 95% Confidence Intervals, CI, 1.63-6.04) and mixed subgroup (HR = 2.89, 95% CI, 1.49-5.62) showed high mortality rates and a significantly increased risk of mortality associated with POD duration as well. CONCLUSIONS: Hyperactive delirium was the most common POD psychomotor subtype, but hypoactive and mixed POD were associated with 6-month mortality risk. Moreover, the risk of death 6 months after surgery increased for both subgroups (hypoactive and mixed) with increasing duration of POD.

Functional and clinical outcomes of patients aged younger and older than 85 years after rehabilitation post-hip fracture surgery in a co-managed orthogeriatric unit.

AIM: Literature investigating rehabilitation outcomes after hip surgery among individuals aged ≥85 years is sparse. We compared the characteristics and outcomes of patients aged under and over 85 years, and assessed factors potentially associated with rehabilitation success as described by the Barthel Index (BI). METHODS: From 2011 to 2014, we prospectively enrolled 328 patients (n = 152 aged <85 years, n = 176 aged ≥85 years) admitted to an orthogeriatric unit (Sondrio, Italy) with a diagnosis of hip fracture requiring surgical treatment. We excluded patients who were being treated conservatively. Outcomes included absolute functional gain (AFG; BI at discharge - BI on admission), rehabilitation effectiveness index (AFG / length of stay) and postoperative complications. RESULTS: Older patients were more functionally (mean BI on admission: 11.7 ± 9.6 vs 16.4 ± 12.2, P < 0.001) and cognitively impaired than their younger counterparts (34.1% vs 18.4%, P < 0.001). Surgery time (1.9 ± 1.2 vs 2.3 ±1.3 days, P = 0.008) and length of stay were shorter for older patients (5.7 ± 2.1 vs 6.6 ± 2.4 days, P < 0.001). There were no differences in terms of complications. Patients aged <85 years showed better functional outcomes (BI, AFG, REI) at discharge than patients aged ≥85 years (mean AFG: 38.2 ± 24.2 vs 26.1 ± 22.0, P < 0.001). BI on admission (OR 1.05, 95% CI 1.02-1.08) and cognitive impairment (OR 0.58, 95% CI 0.34-0.98) were independently associated with rehabilitation outcomes, regardless of chronological age. CONCLUSIONS: Both groups (aged <85 and ≥85 years) showed a significant functional improvement at discharge. Older patients show a residual ability to recover after surgery. A high rehabilitation efficiency - regardless of age - should be pursued even for the oldest old patients experiencing hip fracture. Geriatr Gerontol Int 2018; 18: 1194-1199.

Endoscopic retrograde cholangiopancreatography in the elderly: results of a retrospective study and a geriatricians' point of view.

BACKGROUND: The incidence of biliary tract pathology is growing with an age-related trend, and progresses as the population ages. Endoscopic Retrograde Cholangiopancreatography (ERCP) represents the gold standard for treatment in these cases, but evidence about its safety in the elderly is still debated. METHODS: We retrospectively analyzed the clinical records of all patients aged ≥65 undergoing ERCP between July 2013 and July 2015. Of 387 ERCP cases, 363 (~ 94%) were completed entirely. The mean age of the study population (n = 363) was 79.9 years old (range 70-95), with 190 subjects aged 70-79 and 173 older than 80. We recorded demographics, Charlson Comorbidity index (CCI), American Society of Anesthesiologists (ASA) physical status classification score, indication for the use of the ERCP procedure, and clinical outcomes. Then, we tested all variables to identify the potential risk factors for complications associated with the procedure. RESULTS: The older group (those ≥80 years old) showed significantly more patients with ASA Classes III-IV than the younger one (those ≤79 years old). Interestingly, the CCI was higher in the younger group (p = 0.009). The overall complication rate was 17.3% without inter-group differences. Older age, sex, CCI and intra-ERCP procedures were not related to a higher risk of complications, and the multivariate regression did not identify any of the considered variables to be an independent risk factor for complications. CONCLUSION: ERCP appears as safe in the patients aged 80 years and older, as it is in those aged 70-79 years old in our study, however, a selection bias may affect these findings. A study including a comprehensive geriatric assessment will contribute to shedding light on this issue.

Association of postoperative delirium with markers of neurodegeneration and brain amyloidosis: a pilot study.

The aim of the study was to investigate the association between postoperative delirium (POD) and in vivo markers of Alzheimer's disease pathology in nondemented hip fracture surgery patients. POD was assessed with the Confusion Assessment Method. Amyloid load was quantified on 18F-Flutemetamol positron emission tomography images as standardized uptake value ratio. Secondary outcome measures were gray matter volumes, white matter integrity, and functional connectivity at rest. All the patients with POD (POD+, N = 5) were amyloid negative (standardized uptake value ratio <0.59), whereas 6 out of 11 patients without POD (POD-) showed brain amyloid positivity. POD+ compared to POD- displayed: lower gray matter volumes in the amygdala (p = 0.003), in the middle temporal gyrus and in the anterior cingulate cortex (p < 0.001), increased diffusivity in the genu of the corpus callosum and in the anterior corona radiata (p < 0.05), and higher functional connectivity within the default mode network (p < 0.001). POD patients showed altered gray and white matter integrity in the fronto-limbic regions in absence of brain amyloidosis. Based on this preliminary investigation, delirium pathophysiology might be independent of Alzheimer's disease. Future studies on larger samples are needed to confirm this hypothesis.

Association Between Preoperative Malnutrition and Postoperative Delirium After Hip Fracture Surgery in Older Adults.

OBJECTIVES: To determine whether poor nutritional status can predict postoperative delirium in elderly adults undergoing hip fracture surgery. DESIGN: Prospective observational cohort study. SETTING: Italian orthogeriatric unit. PARTICIPANTS: Individuals aged 70 and older (mean age 84.0 ± 6.6, 74.5% female) consecutively admitted for surgical repair of a proximal femur fracture between September 2012 and April 2016 (N = 415). MEASUREMENTS: Participants underwent a comprehensive geriatric assessment including nutritional status, which was evaluated using the Mini Nutritional Assessment Short Form (MNA-SF). The MNA-SF-based three-class stratification was tested using multivariable logistic regression to assess its role in predicting postoperative delirium (outcome). RESULTS: Seventy-eight malnourished individuals (MNA-SF score 0-7), 185 at risk of malnutrition (MNA-SF score 8-11), and 152 who were well nourished (MNA-SF score 12-14) were compared. On average, individuals with poor nutritional status were more disabled and more cognitively impaired than those who were well nourished and those at risk of malnutrition. Moreover, those who were malnourished were more likely to have postoperative delirium. Multivariate regression analysis adjusted for age, sex, comorbidity, functional impairment, preoperative cognitive status, and American Society of Anesthesiologists score showed that those who were at risk of malnutrition (odds ratio (OR) = 2.42, 95% confidence interval (CI) = 1.29-4.53) and those who were overtly malnourished (OR = 2.98, 95% CI = 1.43-6.19) were more likely to develop postoperative delirium. CONCLUSION: This is the first study in a Western population showing that risk of malnutrition and overt malnutrition, as assessed using the MNA-SF, are independent predictors of postoperative delirium. Accordingly, nutritional status should be assessed in individuals with hip fracture before surgery to determine risk of developing delirium.

Management, prognosis and predictors of unfavourable outcomes in patients newly hospitalized for transient ischemic attack: a real-world investigation from Italy.

BACKGROUND: Understanding the gap between evidence-based recommendations and real-world management is important to inform priority setting and health service planning. METHODS: The 7,776 residents in the Italian Lombardy Region who were newly hospitalized for transient ischemic attack (TIA) during 2008-2009 entered into the cohort and were followed until 2012. Exposure to medical care including selected drugs, diagnostic procedures and laboratory tests was recorded. A composite outcome was employed taking into account all-cause death and hospitalization for stroke and acute myocardial infarction. A multivariable proportional hazards model was fitted to estimate hazard ratio, and 95% confidence intervals (CI), for the exposure-outcome association. RESULTS: During the first year after discharge, 8.6, 49.7 and 48.5% of patients did not use any drugs, diagnostic procedures and laboratory tests respectively. Patients exposed to medical care had 59% reduced risk (95% CI, 50 to 66%) with respect to those who did not use any of these services. CONCLUSIONS: Although the Italian National Health System supplies universal coverage for healthcare, several TIA patients receive suboptimal care. Systematic improvements are necessary in order to improve patient outcomes.

Direct-acting antivirals combination for elderly patients with chronic hepatitis C: A cost-effectiveness analysis.

BACKGROUND: Chronic hepatitis C (CHC) has been undertreated among elderly patients. Interferon-free treatment represents an opportunity for these patients. The aim of this study was to assess the cost-effectiveness of directly acting antivirals (DAAs) in CHC elderly patients. METHODS: A Markov model of CHC natural history was built. This study focuses on CHC patients older than 65 years, stratified according to genotype (1/4, 2 and 3), liver fibrosis (METAVIR F1 to F4), age and frailty phenotype (robust, pre-frail and frail). DAAs combination vs no treatment was simulated for each theoretical population, assessing life years, quality-adjusted life years (QALYs), costs, incremental cost-effectiveness ratios (ICERs) in a lifetime time horizon and by the Healthcare System perspective. RESULTS: Incremental cost-effectiveness ratio increased with age and frailty status in all fibrosis stages. For robust F3 and F4 patients ICERs remained below the willingness-to-pay threshold (WTP) of 40 000€/QALY up to age 75 and 86 years, respectively, depending on drug price and sustained virological response probability (sensitivity analysis). Notably, in F4 and frail subjects older than 75 years, ICER was more sensitive to non-liver-related mortality rate. In elderly F1 and F2 patients, ICERs were below WTP only up to 77 years old, with wide variability among frailty phenotypes. CONCLUSIONS: Cost-effectiveness of DAAs treatment of elderly CHC patients is solid in those with advanced fibrosis, but it depends strongly on frailty status and age, particularly in patients with milder fibrosis stages. Accurate assessment of clinical variables, including frailty, is necessary to allocate limited resources to this special population.

Detecting Delirium Superimposed on Dementia: Evaluation of the Diagnostic Performance of the Richmond Agitation and Sedation Scale.

OBJECTIVES: Delirium disproportionately affects patients with dementia and is associated with adverse outcomes. The diagnosis of delirium superimposed on dementia (DSD), however, can be challenging due to several factors, including the absence of caregivers or the severity of preexisting cognitive impairment. Altered level of consciousness has been advocated as a possible useful indicator of delirium in this population. Here we evaluated the performance of the Richmond Agitation and Sedation Scale (RASS) and the modified-RASS (m-RASS), an ultra-brief measure of the level of consciousness, in the diagnosis of DSD. DESIGN: Multicenter prospective observational study. RASS and m-RASS results were analyzed together, labeled RASS/m-RASS. SETTING: Acute geriatric wards, in-hospital rehabilitation, emergency department. PARTICIPANTS: Patients 65 years and older with dementia. MEASUREMENTS: Delirium was diagnosed with the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) or with the Delirium Rating Scale-Revised (DRS-R-98), or with the 4 A's Test (4AT). Dementia was detected with the Clinical Dementia Rating (CDR) Scale, the Short Form-Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) or via the clinical records. RESULTS: Of the 645 patients included, 376 (58%) had delirium. According to the instrument used to evaluate delirium, the prevalence was 66% with the 4AT, 23% with the DSM, and 100% with the DRS-R-98. Overall a RASS/m-RASS score other than 0 was 70.5% sensitive (95% confidence interval [CI] 65.9%-75.1%) and 84.8% (CI 80.5%-89.1%) specific for DSD. Using a RASS/m-RASS value greater than +1 or less than -1 as a cutoff, the sensitivity was 30.6% (CI 25.9%-35.2%) and the specificity was 95.5% (CI 93.1%-98.0%). The sensitivity and the specificity did not greatly vary according to the method of delirium diagnosis and the dementia ascertainment, although the specificity was slightly higher when the DSM and the IQCODE were used. CONCLUSION: In older patients admitted to different clinical settings, the RASS and m-RASS analyzed as a single group had moderate sensitivity and very high specificity for the detection of DSD. Level of consciousness is therefore a valuable clinical indicator that should form part of delirium screening strategies, although for higher sensitivity other methods of assessment should be used.

Real-world characteristics of hospitalized frail elderly patients with atrial fibrillation: can we improve the current prescription of anticoagulants?

BACKGROUND: In elderly patients, especially those older than 80 years, atrial fibrillation (AF) is associated with an almost 25% increased risk of stroke. Stroke prophylaxis with anticoagulants is therefore highly recommended. The prevalence of factors that have been associated with a lower rate of prescription and adherence to anticoagulant therapy in these patients is little known. The objective of this study was to explore the clinical characteristics of elderly subjects, with and without AF, consecutively admitted to an acute geriatric unit, discussing factors that may decrease the persistence on stroke prophylaxis therapy. We also highlight possible strategies to overcome the barriers conditioning the current underuse of oral anticoagulants in this segment of the population. METHODS: A retrospective observational study was performed on a cohort of elderly patients with and without AF admitted to the Acute Geriatric Unit of San Gerardo Hospital (Monza, Italy). RESULTS: Compared to patients without AF (n = 1216), those with AF (n = 403) had a higher Charlson Comorbidity Index (3 vs. 2, P < 0.001), number of administered drugs (4 vs. 3, P < 0.001), rate of heart failure (36.5% vs. 12%, P < 0.001) and chronic kidney disease (20.6 vs. 13.2, P < 0.001). Many patients with AF were frail (54%) or pre-frail (29%). CONCLUSIONS: Elderly patients with AF have higher rates of conditions that affect adherence to traditional anticoagulant therapy (vitamin K antagonists, VKA). New direct oral anticoagulants (DOAs) can help overcome this problem. In order to prescribe the most appropriate VKA or DOAs, with the best efficacy/safety profile and the highest compliance, a comprehensive geriatric assessment should always accompany the scores for thrombotic and hemorrhagic risk stratification.

Hip Fracture Surgery and Survival in Centenarians.

BACKGROUND: Hip fracture (HF) is increasingly frequent with advancing age. Studies describing the HF incidence rate and survival after surgery in centenarians are scanty. To fill this gap, we performed a large population-based investigation on Lombardy centenarians (Italy). METHODS: Retrospective observational cohort study based on information from the Healthcare Utilization Database. Among the cohort of 7,830 residents that reached 100 years of age between 2004 and 2011, incidence rate of HF was calculated. Two hundred fifty-nine patients were discharged alive from a hospital after HF and surgical repair (HF cohort). For each HF cohort member, a control was randomly selected from the initial cohort to be matched for gender and date of birth, and who did not experience HF from the date of their hundredth birthday until the date of hospital discharge of the corresponding HF cohort member. The survival curves and the hazard functions of HF and control cohort were calculated within 2 years. RESULTS: Over a mean follow-up of 1.85 years, HF incidence rate was 23.1 per 1,000 centenarians per year. Survival probability was significantly lower in HF cohort than in control cohort (31.5 vs 48.1%, p < .001). Hazard functions showed an increased risk of death in HF cohort than in control cohort, especially in the 3 months after surgery. CONCLUSION: Survival analysis exhibited an excess mortality in the first 3 months among HF cohort members, but not beyond this period. Every effort to counteract HF is warranted, including prevention of falls and high quality of care, especially in the early postsurgical time.

The Effect of an Impaired Arousal on Short- and Long-Term Mortality of Elderly Patients Admitted to an Acute Geriatric Unit.

OBJECTIVE: Impaired arousal is associated with negative outcomes in intensive care units, but studies in acute medical wards are scanty. The study aim was to evaluate the association between impaired arousal, as measured using an ultrabrief screen, and risk of both 1- and 6-month mortality and discharge to nursing home (NH) or hospice. DESIGN: Prospective cohort study with 6-month follow-up. SETTING: An acute geriatric unit (AGU) of a university-based hospital in Northern Italy. PARTICIPANTS: All patients aged 65 years or older, admitted to the AGU between September 2012 and February 2015. MEASUREMENTS: The modified Richmond Agitation Sedation Scale (m-RASS) was used to assess patients' arousal; a score of 0 denotes normal arousal, scores ranging from +1 to +4 denote increased arousal, and scores ranging from -1 to -5 denote decreased levels. The association of m-RASS scores with 6-month mortality was assessed by a Kaplan-Meier analysis. The impact of impaired arousal, defined by the m-RASS as anything other than "awake and alert," was determined using Cox proportional hazard regression for 1- and 6-month mortality after admission and logistic regressions were used for discharge to NH or hospice. The models were adjusted for age, sex, dementia, Sequential Organ Failure Assessment score, and disability. RESULTS: Patients (n = 2477) had a mean age of 84 years, and were predominantly women (59.8%). Impaired arousal on admission was present in 644 (25.9%) patients: 33 (1.3%) were comatose (m-RASS = -5), 56 (2.3%) awakened to pain only (m-RASS = -4), 43 (1.7%) were very drowsy (m-RASS = -3), 93 (3.8%) drowsy (m-RASS = -2), and 212 (8.6%) were slightly drowsy (m-RASS = -1), but there were also 110 (4.4%) patients with restlessness, 75 (3.0%) with agitation, 17 (0.7%) with severe agitation, and 3 (0.1%) with combative behavior. Globally, 337 patients died within 1 month and 689 patients within 6 months. After adjustment for covariates, patients with impaired arousal had a significantly higher chance of having died at 1-month (adjusted hazard ratio [HR] 1.56, 95% confidence interval [CI] 1.22-2.03) and 6-month follow-up (adjusted HR 1.31, 95% CI 1.10-1.57). Those with impaired arousal were more likely to be discharged to a new NH (odds ratio [OR] 1.75, 95% CI 1.19-2.57) or to hospice (OR 1.96, 95% CI 1.18-3.23) than those without impaired arousal. CONCLUSIONS: An abnormal arousal level is an independent predictor of increased risk of 1- and 6-month mortality and of discharge to a new NH or hospice. The assessment of arousal with m-RASS should be routinely performed on all older patients on admission to acute hospital wards to screen potentially critical conditions.

Takotsubo cardiomyopathy in an 81-year-old woman after injection of bone cement during hemiarthroplasty: An orthogeriatric case report.

INTRODUCTION: Takotsubo cardiomyopathy is a syndrome characterized by transient cardiac ischemia-like symptoms, such as chest pain, increase of myocardial necrosis markers, electrocardiographic changes, and temporary left ventricular apical ballooning without significant coronary artery disease, often triggered by a particularly stressful situation. The association between Takotsubo and hip fracture surgery has been rarely reported in the literature. PRESENTATION OF CASE: An 81-year-old woman was hospitalized with a diagnosis of right femoral neck fracture. During the surgical procedure, she displayed acute coronary symptoms a few minutes after the injection of bone cement, in the absence of coronary lesions. Due to the time relationship, bone cement implantation syndrome - not uncommon to observe - was considered in the differential diagnosis. However, the instrumental findings and the transient nature of the abnormalities guided us toward a diagnosis of Takotsubo. The treatment with Levosimendan, Amiodarone, and Metoprolol allowed gradual and satisfactory recovery of the cardiac function within a few days. The follow-up performed two and six months after surgery revealed complete cardiac recovery, and ability to walk at home comparable to the pre-fracture situation. DISCUSSION: Takotsubo cardiomyopathy is more common in women during the postmenopausal phase, especially if undergoing stressful physical or emotional stimuli. In this case, the sequence of hip fracture, pain, hospitalization, and surgery could easily be intended as a strong stressful event with high physical/psychological burden. CONCLUSION: Despite the good prognosis associated with early recognition, Takotsubo represents a life-threatening adverse event. Considering its possible pathogenesis, a "gentle care" approach and the optimization of pain control must be pursued in elderly subjects with hip fracture, aiming at reducing the stress of the hospitalization and related procedures.

Aging in Italy: The Need for New Welfare Strategies in an Old Country.

Italy, a Southern European country with 60.8 million inhabitants, has the largest proportion of elderly citizens (aged ≥65) in Europe of 21.4%. The aging of the population is due to a number of reasons, such as baby boomers growing old, an increase in longevity, and low birth rate. Although international migration has increased in recent years, the addition of a foreign segment of the population has neither compensated for nor significantly curtailed the aging phenomenon. The impact of aging on the economic sustainability concerns the progressive reduction of the workforce, high incidence of pension spending in the overall resources allocated to welfare, recent reform of the pension system, and the growing issue of "non-self-sufficiency" in the elderly. Despite limited financial measures dedicated to research, Italy is conducting important studies on aging, both at the national and international level. Physicians and researchers in the field of geriatrics and gerontology are not only promoting quality of life in the elderly, and healthy-active aging, but also contributing to economic stability and social organization. Finally, nutritional and lifestyle habits-and their role in preventing chronic diseases-are the focus of the current international event EXPO 2015, with many sections dedicated to the elderly.