Prognostic Role of NECPAL CCOMS-ICO Tool on One-Year Mortality in a Hospitalized Older Population.

Background: It is essential to establish both the appropriateness of palliative care (PC) and the prognosis in daily clinical practice to guide decision making in the management of older people with multiple advanced chronic diseases. Objectives: We assessed patients who were appropriate for PC using the NECPAL tool in a hospitalized older population and then we investigated its predictive validity on one-year mortality compared with the multidimensional prognostic index (MPI), a validated geriatric prognostic tool. Design: Prospective cohort study. Setting/Subjects: We enrolled 103 older adults hospitalized for acute medical and surgical conditions in a geriatric hospital in Italy. Measurements: The variables of interest were obtained at baseline through interviews of the ward medical staff and by consulting the computerized medical records. Long-term mortality (one-year) was assessed through the analysis of data acquired from hospital or territorial databases or through telephone contact with caregivers. Results: Mean age was 86.8 ± 7.2 years, with a female prevalence of 54.4%. Prevalence of NECPAL+ patients was 65.1%. MPI low risk: 30.1%; moderate risk: 41.7%; severe risk: 28.2%. Patients deceased during follow-up were 54.4%. NECPAL+ patients were more likely to die, even after adjusting for age, sex, and MPI score (hazard ratio [HR] 2.7, p = 0.020). All the NECPAL categories were associated with one-year mortality. MPI showed a better predictive power than NECPAL (area under the curve [AUC] 0.85 vs. 0.75, p = 0.030). After the exclusion of "Comorbidity: ≥2 concurrent diseases" item from NECPAL, its AUC increased to 0.78 with no statistically significant differences from MPI (p = 0.122). Conclusions: NECPAL is useful to identify the appropriateness of PC in hospitalized older adults, also allowing to predict long-term mortality with a performance similar to that of a validated geriatric prognostic tool.

The 4-DSD: A New Tool to Assess Delirium Superimposed on Moderate to Severe Dementia.

OBJECTIVES: The purpose of this study was to create, standardize, and validate a new instrument, named 4-DSD, and determine its diagnostic accuracy in the diagnosis of delirium in subjects with moderate to severe dementia. DESIGN: Multicenter cross-sectional observational study. SETTING AND PARTICIPANTS: Older patients consecutively admitted to acute and rehabilitation hospital wards. MEASURES: The DSM-5 was used as the reference standard delirium assessment. The presence and severity of dementia was defined using the AD8 and the Global Deterioration Scale (GDS). The 4-DSD is a 4-item tool that ranges from 0 to 12. Item 1 measures alertness, item 2 altered function, item 3 attention, and item 4 acute change or fluctuation in mental status. RESULTS: A total of 134 patients were included in the study. Most of the patients were enrolled in acute hospital wards (60%), with 40% in rehabilitation settings. A minority of the patients were categorized with moderate dementia, with a GDS score of 5 (4%). Most of the patients were in the moderate-severe stage with a GDS score ≤6 (77%); 19% were classed as severe, with a GDS score of 7. A 4-DSD cutoff score ≥5 had a sensitivity of 80% and specificity of 80% with a positive predictive value (PPV) of 67% and a negative predictive value (NPV) of 89%. In the subgroup with moderate-severe dementia (n = 108), the sensitivity and the specificity were 79% and 82%, respectively, with a PPV and NPV of 62% and 92%. In the subgroup with severe dementia (n = 26) the sensitivity was 82% and the specificity 56% with a PPV of 78% and a NPV of 63%. CONCLUSIONS AND IMPLICATIONS: The availability of a specific tool to detect delirium in patients with moderate-severe dementia has important clinical and research implications, allowing all health care providers to improve their ability to identify it.

A Point Prevalence Study of Delirium in Italian Nursing Homes.

BACKGROUND: Delirium is a common geriatric syndrome. Few studies have been conducted in nursing home (NH) residents. The aim of this project was to perform a point prevalence study of delirium in Italian NHs. METHODS: Data collected in 71 NHs are presented. Inclusion criteria were age ≥65 years and native Italian speaker. Exclusion criteria were coma, aphasia, and end-of-life status. Sociodemographic and medical data were recorded. Delirium was assessed using the Assessment Test for Delirium and Cognitive Impairment (4-AT). Patients with a 4-AT score ≥4 were considered to have delirium. Motor subtype was evaluated using the Delirium Motor Subtype Scale (DMSS). RESULTS: A total of 1,454 patients were evaluated (mean age 84.4 ± 7.4 years, 70.2% female), of whom 535 (36.8%) had delirium. In multivariate logistic regression analysis, variables significantly associated with delirium were education (OR 0.94, 95% CI 0.91-0.97), dementia (OR 3.12, 95% CI 2.38-4.09), functional dependence (OR 6.13, 95% CI 3.08-12.19 for ADL score 0; OR 1.99, 95% CI 1.03-3.84 for ADL score 1-5), malnutrition (OR 4.87, 95% CI 2.68-8.84), antipsychotics (OR 2.40, 95% CI 1.81-3.18), and physical restraints (OR 2.48, 95% CI 1.71-3.59). CONCLUSION: Delirium is common in older NH residents. Simple assessment tools might facilitate its recognition in this vulnerable population.

Pattern of use and presenting complaints of older patients visiting an Emergency Department in Italy.

BACKGROUND AND AIMS: The number of older persons admitted to the Emergency Department (ED) is dramatically increasing due to their complex medical and social problems, which in turn lead to longer clinical evaluation times and increased use of resources compared to younger adults. However, scant data are available for Italian EDs. Similarly, no data are available about the reasons to ED visit and its role in determining the ED utilization pattern. The study aimed at describing the pattern of ED use by older patients and main presenting complaints. METHODS: Cross-sectional descriptive study of 5,826 ED patients in the city of Fano (Italy). Identifiers and triage, clinical and social data were collected. Presenting complaints as recorded by triage nurses have been recoded according to the Canadian Emergency Department Information System list version 1.1. Data were analyzed comparing older patients (more than 65 years-old) with younger adults (less than 65 years-old). RESULTS: The prevalence of ED visits by older adults was 23.9 %. Their visits were characterized by higher emergency levels, admission rate and length of ED stay. Trauma was the main reason for ED presentation, especially among young adults, but elderly trauma patients were more frequently admitted because of hip fracture. Dyspnea and abdominal pain were the most frequent non-trauma presenting complaints among geriatric patients and represented the main causes for admission. CONCLUSIONS: Older adults use the ED appropriately also in Italy. Trauma with complications (fracture) and various presenting complaints underlying medical problems accounted for more than 50 % of ED visits and hospital admissions.

Risk stratification of older patients in the emergency department: comparison between the Identification of Seniors at Risk and Triage Risk Screening Tool.

BACKGROUND AND OBJECTIVES: The increasing number of elderly patients accessing emergency departments (ED) requires use of validated, rapid assessment instruments. The aim of this study was to compare the Identification of Seniors at Risk (ISAR) and Triage Risk Screening Tool (TRST), based on direct patient evaluation. RESEARCH DESIGN AND SUBJECTS: This study was a prospective observational study with 6 months follow-up. Subjects were 2,057 residents in the Marche Region, aged 65 or more years, accessing the first-level ED of a geriatric hospital in Ancona, Italy, over a 6-month period. METHODS: ISAR and TRST were administered at triage by nurse. Outcomes were in need of hospital admission and mortality at the index ED access, early (within 30 days) and late ED revisit, hospitalization, and death in 6 months. RESULTS: ISAR (cutoff of≥2) was positive in 68% of patients, whereas 64% were TRST-positive. The two scores were significantly correlated and had similar areas under the receiver operating characteristic (ROC) curves in predicting hospital admission (ISAR, 0.68; TRST, 0.66) and mortality (ISAR, 0.74; TRST, 0.68), as well as early ED revisit (ISAR, 0.63; TRST, 0.61). In the 6-month follow-up of patients discharged alive, the tools predicted comparably ED return visit (ISAR, 0.60; TRST, 0.59), hospital admission (ISAR, 0.63; TRST, 0.60), and mortality (ISAR, 0.74; TRST, 0.73). A similar performance was observed in the subgroup of participants discharged directly from the ED. CONCLUSIONS: Risk stratification of elderly ED patients with ISAR or TRST is substantially comparable for selecting elderly ED patients who could benefit from geriatric interventions. ISAR had slightly higher sensitivity and lower specificity than TRST.

Prognostic stratification of elderly patients in the emergency department: a comparison between the "Identification of Seniors at Risk" and the "Silver Code".

BACKGROUND: The increasing number of elderly patients accessing emergency departments (EDs) requires use of validated assessment tools. We compared the Identification of Seniors at Risk (ISAR), using direct patient evaluation, with the Silver Code (SC), based on administrative data. METHODS: Subjects aged 75+ years accessing a geriatric ED over an 8-month period were enrolled. Outcomes were need for hospital admission and mortality at the index ED access, ED return visit, hospitalization, and death at 6 months. RESULTS: Of 1,632 participants (mean age 84 ± 5.5 years), 75% were ISAR positive, and the sample was homogeneously distributed across the four SC risk categories (cutoffs of 0-3, 4-6, 7-10, and 11+). The two scores were mildly correlated (r = .350, p < .001) and had a similar area under the receiver-operating characteristic curve in predicting hospital admission (ISAR: 0.65, SC: 0.63) and mortality (ISAR: 0.72, SC: 0.70). ISAR-positive subjects were at greater risk of hospitalization and death (odds ratio 2.68 and 5.23, respectively, p < .001); the risk increased across SC classes (p < .001). In the 6-month follow-up of discharged patients, the tools predicted similarly ED return visit, hospital admission, and mortality. The SC predicted these outcomes even in participants not hospitalized at the index ED access. CONCLUSIONS: Prognostic stratification of elderly ED patients with the SC is comparable with that obtained with direct patient evaluation. The SC, previously validated in hospitalized patients, predicts ED readmissions and future hospitalizations even in patients discharged directly from the ED.

Predictive validity of the Identification of Seniors At Risk (ISAR) screening tool in elderly patients presenting to two Italian Emergency Departments.

BACKGROUND AND AIMS: Elderly patients presenting to Emergency Departments (ED) have complex health problems and often undergo adverse outcomes after an ED visit. In Canadian ED, the Identification of Seniors At Risk (ISAR) is useful in screening for these aspects. This study evaluated the predictive validity of ISAR for elderly patients presenting to Italian ED. METHODS: Prospective observational study of a cohort of 200 elderly patients presenting to two urban ED in Ancona (Italy). Identifiers and triage, clinical and social data were collected, and the ISAR was administered. The following single outcomes were considered: early (30-day) and late (6-month) ED revisit, frequent ED return, hospital admission, and functional decline. Composite outcomes were: [1] death, long-term care (LTC) placement, functional decline; [2] the same as [1] plus any ED revisit or hospitalization. Odds ratios (OR) and 95% confidence intervals (CI) were calculated. RESULTS: ISAR was positive for 141 (70.5%) subjects, who had high comorbidity, disability and cognitive impairment. ISAR-positive patients had an OR of 4.77 (95% CI, 2.19-10.42) to undergo composite outcome [1] and of 3.46 (95% CI, 1.68-7.15) to experience composite outcome [2]. ISAR also predicted ED revisit and frequent use, hospitalization and functional decline at 6 months. ISAR was also an independent predictor of 6-month mortality (Hazard Ratio 6.9, 95% CI 1.65-29, p=0.008). CONCLUSIONS: ISAR can be used as a screening test to identify Italian elderly ED patients who have an increased 6-month risk of death, LTC placement, functional decline, ED revisit, or hospitalization.

A geriatric emergency service for acutely ill elderly patients: pattern of use and comparison with a conventional emergency department in Italy.

The current disease-oriented, episodic model of emergency care does not adequately address the complex needs of older adults presenting to emergency departments (EDs). Dedicated ED facilities with a specific organization (e.g., geriatric EDs (GEDs)) have been advocated. One of the few GED experiences in the world is described and its outcomes compared with those of a conventional ED (CED). In a secondary analysis of a prospective observational cohort of 200 acutely ill elderly patients presenting to two urban EDs in Ancona, Italy, identifiers and triage, clinical, and social data were collected and the following outcomes considered: early (30-day) and late (6-month) ED revisit, frequent ED return, hospital admission, and functional decline. Death, functional decline, any ED revisit and any hospital admission were also considered as a composite outcome. Odds ratios and 95% confidence intervals (CIs) were calculated. Overall, GED patients were older and frailer than CED patients. The two EDs did not differ in terms of early, late, or frequent ED return or in 6-month hospital admission or functional decline. The mortality rate was slightly but significantly lower in the GED patients (hazard ratio=0.47, 95% CI=0.22-0.99, P=.047). The data suggest noninferiority and, indirectly, a slight superiority for the GED system in the acute care of elderly people, supporting the hypothesis that ED facilities specially designed for older adults may provide better care.

Mini Nutritional Assessment (short form) and functional decline in older patients admitted to an acute medical ward.

BACKGROUND AND AIMS: Protein and/or energy malnutrition is common in hospitalized older patients and is associated with poor outcomes. Among recommended nutritional screening tools, contrasting data exist about the usefulness of the Mini Nutritional Assessment Short-Form (MNA-SF). We evaluated whether the MNA-SF, alone or integrated with serum albumin levels, is a reliable predictor of functional decline in older patients. METHODS: We studied 275 elderly patients (mean age 76.5, 60.7% males) admitted to an acute medical ward of a tertiary-care teaching hospital over a 12-month period. In this observational study, we evaluated nutritional status, with the MNA-SF alone or integrated with albumin. Data were collected at admission and related to laboratory and geriatric assessment features, and length of stay (LOS). Functional decline (defined as a loss >or=10% in terms of Barthel Index score at discharge compared with 2 weeks before admission) was considered as outcome. RESULTS: The MNA-SF estimated 46% patients at risk of malnutrition. These subjects had worse clinical features (lower total cholesterol and albumin levels), longer LOS (13.3 vs 11.2 days, p=0.014) and considerable functional decline (OR 4.25, 95% CI 1.83-9.9, p=0.001). Integrating the MNA-SF with albumin values, we obtained an effective instrument to detect older inpatients with protein-energy malnutrition, at higher risk of undergoing functional decline (OR 16.19, 95% CI 4.68-56.03, p<0.0001). CONCLUSIONS: The MNA-SF is a useful screening tool for hospitalized elders at risk of malnutrition. It is associated with poor clinical outcomes and is able to predict functional decline. Together with hypoalbuminemia, it better identifies patients with true protein-energy malnutrition.

A manual of guidelines to score the modified cumulative illness rating scale and its validation in acute hospitalized elderly patients.

OBJECTIVES: To update previous guidelines to score the Cumulative Illness Rating Scale (CIRS) and test their usefulness in hospitalized elderly patients. DESIGN: The CIRS was scored retrospectively in a cohort of elderly patients followed for 18 months. SETTING: An acute internal medicine ward in an academic tertiary care hospital. PARTICIPANTS: Three hundred eighty-seven patients aged 65 and older. MEASUREMENTS: The CIRS was retrospectively scored for the enrolled patients. Intrarater and interrater reliability were calculated. Two illness severity indices (total score (TSC) and severity (SV)) and one comorbidity index (CM) were obtained. Clinical features and comprehensive geriatric assessment (CGA) variables were also used. All patients underwent an 18-month follow-up for mortality and rehospitalization. RESULTS: Intrarater and interrater reliability of the CIRS scored following the guidelines was good (intraclass correlation coefficients of 0.83 and 0.81, respectively). The TSC, SV, and CM correlated with clinical features (laboratory values, medication usage, and length of in-hospital stay) and CGA variables (cognitive impairment, depression and disability). All three indices were able to predict 18-month mortality and rehospitalization rates. CONCLUSION: This study confirmed the validity of the CIRS as an indicator of health status and demonstrated its ability to predict 18-month mortality and rehospitalization in hospitalized elderly patients. The availability of detailed guidelines for scoring the CIRS can improve its usefulness and facilitate more-widespread use for research and clinical aims.

Prevention of cardiovascular events in early menopause: a possible role for hormone replacement therapy.

Heart disease is a major cause of illness and death in women. It is well known that there is an increase in cardiovascular disease and cardiovascular risk factors after the menopause, but it is still unclear whether the change in risk factors after the menopause is only related to the aging process or is principally due to estrogen deprivation. Observational studies suggest a protective role for estrogens, whereas recent randomized controlled trials report a negative effect of oral estrogens on primary and secondary prevention of cardiovascular events. The role of inflammation in the process of atherogenesis and in determining the cardiovascular disease risk in postmenopausal women has been focused only recently as well as the role of the estrogen receptor system in different tissues and the role of genetic susceptibility to adverse events during estrogen therapy. The objective of this work was to review the current understanding of the relationships between cardiovascular disease risk factors and hormonal age-related changes in postmenopausal women and particularly in early and surgical postmenopausal women, for a more appropriate evaluation of the expected effects of therapy with exogenous estrogens in a specific sample of the large population of postmenopausal women.