Brand new norms for a good old test: Northern Italy normative study of MiniMental State Examination.

AIM: Mini-Mental State Examination (MMSE) is one of the most used tests for the screening of global cognition in patients with neurological and medical disorders. Norms for the Italian version of the test were published in the 90 s; more recent norms were published in 2020 for Southern Italy only. In the present study, we computed novel adjustment coefficients, equivalent scores and cut-off value for Northern Italy (Lombardia and Veneto) and Italian speaking Switzerland. METHODS: We recruited 361 healthy young and old (range: 20-95 years) individuals of both sexes (men: 156, women: 205) and from different educational levels (range: 4-22 years). Neuropsychiatric disorders and severe medical conditions were excluded with a questionnaire and cognitive deficits and were ruled out with standardized neuropsychological tests assessing the main cognitive domains. We used a slightly modified version of MMSE: the word 'fiore' was replaced with 'pane' in verbal recalls to reduce the common interference error 'casa, cane, gatto'. The effect of socio-demographic features on performance at MMSE was assessed via multiple linear regression, with test raw score as dependent variable and sex, logarithm of 101-age and square root of schooling as predictors. RESULTS: Mean raw MMSE score was 28.8 ± 1.7 (range: 23-30). Multiple linear regression showed a significant effect of all socio-demographic variables and reported a value of R2 = 0.26. The new cut off was ≥ 26 /30. CONCLUSION: We provide here updated norms for a putatively more accurate version of Italian MMSE, produced in a Northern population but potentially valid all over Italy.

Understanding Factors Associated With Psychomotor Subtypes of Delirium in Older Inpatients With Dementia.

OBJECTIVES: Few studies have analyzed factors associated with delirium subtypes. In this study, we investigate factors associated with subtypes of delirium only in patients with dementia to provide insights on the possible prevention and treatments. DESIGN: This is a cross-sectional study nested in the "Delirium Day" study, a nationwide Italian point-prevalence study. SETTING AND PARTICIPANTS: Older patients admitted to 205 acute and 92 rehabilitation hospital wards. MEASURES: Delirium was evaluated with the 4-AT and the motor subtypes with the Delirium Motor Subtype Scale. Dementia was defined by the presence of a documented diagnosis in the medical records and/or prescription of acetylcholinesterase inhibitors or memantine prior to admission. RESULTS: Of the 1057 patients with dementia, 35% had delirium, with 25.6% hyperactive, 33.1% hypoactive, 34.5% mixed, and 6.7% nonmotor subtype. There were higher odds of having venous catheters in the hypoactive (OR 1.82, 95% CI 1.18-2.81) and mixed type of delirium (OR 2.23, CI 1.43-3.46), whereas higher odds of urinary catheters in the hypoactive (OR 2.91, CI 1.92-4.39), hyperactive (OR 1.99, CI 1.23-3.21), and mixed types of delirium (OR 2.05, CI 1.36-3.07). We found higher odds of antipsychotics both in the hyperactive (OR 2.87, CI 1.81-4.54) and mixed subtype (OR 1.84, CI 1.24-2.75), whereas higher odds of antibiotics was present only in the mixed subtype (OR 1.91, CI 1.26-2.87). CONCLUSIONS AND IMPLICATIONS: In patients with dementia, the mixed delirium subtype is the most prevalent followed by the hypoactive, hyperactive, and nonmotor subtype. Motor subtypes of delirium may be triggered by clinical factors, including the use of venous and urinary catheters, and the use of antipsychotics. Future studies are necessary to provide further insights on the possible pathophysiology of delirium in patients with dementia and to address the optimization of the management of potential risk factors.

Drug Prescription and Delirium in Older Inpatients: Results From the Nationwide Multicenter Italian Delirium Day 2015-2016.

OBJECTIVE: This study aimed to evaluate the association between polypharmacy and delirium, the association of specific drug categories with delirium, and the differences in drug-delirium association between medical and surgical units and according to dementia diagnosis. METHODS: Data were collected during 2 waves of Delirium Day, a multicenter delirium prevalence study including patients (aged 65 years or older) admitted to acute and long-term care wards in Italy (2015-2016); in this study, only patients enrolled in acute hospital wards were selected (n = 4,133). Delirium was assessed according to score on the 4 "A's" Test. Prescriptions were classified by main drug categories; polypharmacy was defined as a prescription of drugs from 5 or more classes. RESULTS: Of 4,133 participants, 969 (23.4%) had delirium. The general prevalence of polypharmacy was higher in patients with delirium (67.6% vs 63.0%, P = .009) but varied according to clinical settings. After adjustment for confounders, polypharmacy was associated with delirium only in patients admitted to surgical units (OR = 2.9; 95% CI, 1.4-6.1). Insulin, antibiotics, antiepileptics, antipsychotics, and atypical antidepressants were associated with delirium, whereas statins and angiotensin receptor blockers exhibited an inverse association. A stronger association was seen between typical and atypical antipsychotics and delirium in subjects free from dementia compared to individuals with dementia (typical: OR = 4.31; 95% CI, 2.94-6.31 without dementia vs OR = 1.64; 95% CI, 1.19-2.26 with dementia; atypical: OR = 5.32; 95% CI, 3.44-8.22 without dementia vs OR = 1.74; 95% CI, 1.26-2.40 with dementia). The absence of antipsychotics among the prescribed drugs was inversely associated with delirium in the whole sample and in both of the hospital settings, but only in patients without dementia. CONCLUSIONS: Polypharmacy is significantly associated with delirium only in surgical units, raising the issue of the relevance of medication review in different clinical settings. Specific drug classes are associated with delirium depending on the clinical setting and dementia diagnosis, suggesting the need to further explore this relationship.

Association between delirium, adverse clinical events and functional outcomes in older patients admitted to rehabilitation settings after a hip fracture: A multicenter retrospective cohort study.

AIM: The aim of the present study is to investigate how delirium and adverse clinical events (ACE) contribute independently and in combination to functional outcomes in older patients admitted to rehabilitation settings after a hip fracture. METHODS: This is a multicenter retrospective cohort study of patients aged ≥65 years admitted after hip fracture surgical repair to three Italian rehabilitation units. Delirium on admission was evaluated with the Confusion Assessment Method. ACE during the rehabilitation stay were recorded, including infections (i.e. urinary tract infections, other infections), non-infectious ACE (i.e. cardiovascular events, respiratory failure, pulmonary embolism) and falls. A multivariable linear regression was used to evaluate the effect of ACE and delirium on functional outcome, adjusting for covariates determined a priori. RESULTS: A total of 519 patients were included in the study. The mean ± SD age was 82.9 ± 9.4 years. ACE occurred in 277 patients (53.4%), delirium alone was present in 19 patients (3.6%). Both conditions were present in 58 patients (11.2%). Compared with patients without delirium or ACE, those with ACE or delirium were more likely to have a worse functional outcome (-6.7 Barthel Index points [-11.6; -1.7]; P = 0.008; -13.2 [-25.6; -0.8]; P = 0.038) at discharge, and patients with both conditions had an even lower Barthel Index score (-18.6 Barthel Index points [-26.9; -10.3]; P < 0.001). CONCLUSIONS: ACE and delirium are very common in older patients admitted to rehabilitation settings after hip fracture, and frequently coexist. As both ACE and delirium could impact on functional outcome, alone and in combination, a clinical geriatric approach is necessary for this population to minimize risks. Geriatr Gerontol Int 2019; 19: 404-408.

The association of indwelling urinary catheter with delirium in hospitalized patients and nursing home residents: an explorative analysis from the "Delirium Day 2015".

BACKROUND: Use of indwelling urinary catheter (IUC) in older adults has negative consequences, including delirium. AIM: This analysis, from the "Delirium Day 2015", a nationwide multicenter prevalence study, aim to evaluate the association of IUC with delirium in hospitalized and Nursing Homes (NHs) patients. METHODS: Patients underwent a comprehensive geriatric assessment, including the presence of IUC; inclusion criteria were age > 65 years, being Italian speaker and providing informed consent; exclusion criteria were coma, aphasia, end-of-life status. Delirium was assessed using the 4AT test (score ≥ 4: possible delirium; scores 1-3: possible cognitive impairment). RESULTS: Among 1867 hospitalized patients (mean age 82.0 ± 7.5 years, 58% female), 539 (28.9%) had IUC, 429 (22.9%) delirium and 675 (36.1%) cognitive impairment. IUC was significantly associated with cognitive impairment (OR 1.60, 95% CI 1.19-2.16) and delirium (2.45, 95% CI 1.73-3.47), this latter being significant also in the subset of patients without dementia (OR 2.28, 95% CI 1.52-3.43). Inattention and impaired alertness were also independently associated with IUC. Among 1454 NHs residents (mean age 84.4 ± 7.4 years, 70.% female), 63 (4.3%) had IUC, 535 (36.8%) a 4AT score ≥ 4, and 653 (44.9%) a 4AT score 1-3. The multivariate logistic regression analysis did not show a significant association between 4AT test or its specific items with IUC, neither in the subset of patients without dementia. DISCUSSION: We confirmed a significant association between IUC and delirium in hospitalized patients but not in NHs residents. CONCLUSION: Environmental and clinical factors of acute setting might contribute to IUC-associated delirium occurrence.

Delirium, Dementia, and In-Hospital Mortality: The Results From the Italian Delirium Day 2016, A National Multicenter Study.

BACKGROUND: There is little evidence about the prevalence of cognitive disorders and their effect on in-hospital mortality in large multicenter studies. The objectives of the 2016th edition of the "Italian Delirium Day," a large multicenter study on in-hospital older patients, were to assess (i) the point prevalence of cognitive impairment/no dementia, dementia, delirium, and delirium superimposed on dementia and (ii) the effect of these conditions on in-hospital mortality. METHODS: This multicenter study and included 2,037 older patients (aged ≥65 years) admitted to acute medical and surgical wards across 205 acute hospitals. The four cognitive disorders groups were defined with a structured approach including the four AT and the presence of a documented diagnosis of dementia. The outcome measure was in-hospital mortality, as reported by the researchers involved in the study in each center. RESULTS: The mean age was 81.17 ± 7.7 years. Overall, 893 patients (43.8%) had neither delirium nor dementia nor cognitive impairment, 483 (23.7%) had cognitive impairment/no dementia, 230 (11.3%) dementia alone, 187 (9.2%) delirium alone, and 244 (12.0%) delirium superimposed on dementia. Overall, 99 (4.8%) patients died. Participants with delirium alone (odds ratio 2.56; 95% confidence interval: 1.29-5.09) and those with delirium superimposed on dementia (odds ratio 2.60; 95% confidence interval: 1.39-4.85) had higher mortality risk compared with the reference group of patients with "no cognitive impairment." CONCLUSIONS: Delirium and delirium superimposed on dementia were highly prevalent among older hospitalized patients and significantly increased in-hospital mortality. Clinicians should systematically assess these conditions and recognize them as markers of critical conditions and predictors of imminent death.

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 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.

Recognition of Delirium Features in Clinical Practice: Data from the "Delirium Day 2015" National Survey.

BACKGROUND/OBJECTIVES: Delirium is underrecognized in clinical practice. The primary aim of the present multicenter study was to compare the ability of nurses to identify delirium features with a standardized assessment. The secondary aim was to identify predictors of missed or incorrect identifications of delirium by nurses. DESIGN: Point prevalence study in 120 wards across Italy. SETTING: "Delirium Day 2015." PARTICIPANTS: Inpatients aged 65 and older (N = 1,867). MEASUREMENTS: Participants and nurses were asked specific questions to investigate their perceptions of the presence of delirium features (acute cognitive change, inattention, cognitive fluctuations, impaired arousal). Delirium was identified according to the results of the Assessment Test for Delirium and Cognitive Impairment (4AT), completed by a physician. Comorbidities including dementia, disability, drug treatments, and delirium motor subtype according to the Delirium Motor Subtype Scale were recorded. RESULTS: Delirium was present in 429 subjects (23%) according to the 4AT. Cognitive fluctuations was the delirium feature that the nurses most often recognized. Nurses' perceptions of acute cognitive change, cognitive fluctuations, or impaired arousal had 84% sensitivity and 81% specificity for delirium. The nonmotor subtype of delirium was less likely to be recognized (80%) than the hyperactive (97%), mixed (92%), and hypoactive (90%) subtypes. Incorrect perception of delirium was more frequent in subjects with dementia (specificity 64%). CONCLUSIONS: The delirium feature that nurses were best able to recognize was cognitive fluctuations. The nonmotor subtype was associated with a lower recognition rate. Routine observation and registration of delirium features by nurses in clinical practice might be helpful to increase formal diagnosis of delirium.

Clinical Features Associated with Delirium Motor Subtypes in Older Inpatients: Results of a Multicenter Study.

OBJECTIVE: To date motor subtypes of delirium have been evaluated in single-center studies with a limited examination of the relationship between predisposing factors and motor profile of delirium. We sought to report the prevalence and clinical profile of subtypes of delirium in a multicenter study. METHODS: This is a point prevalence study nested in the "Delirium Day 2015", which included 108 acute and 12 rehabilitation wards in Italy. Delirium was detected using the 4-AT and motor subtypes were measured with the Delirium Motor Subtype Scale (DMSS). A multinomial logistic regression was used to determine the factors associated with delirium subtypes. RESULTS: Of 429 patients with delirium, the DMSS was completed in 275 (64%), classifying 21.5% of the patients with hyperactive delirium, 38.5% with hypoactive, 27.3% with mixed and 12.7% with the non-motor subtype. The 4-AT score was higher in the hyperactive subtype, similar in the hypoactive, mixed subtypes, while it was lowest in the non-motor subtype. Dementia was associated with all three delirium motor subtypes (hyperactive, OR 3.3, 95% CI: 1.2-8.7; hypoactive, OR 2.8, 95% CI: 1.2-6.5; mixed OR 2.6, 95% CI: 1.1-6.2). Atypical antipsychotics were associated with hypoactive delirium (OR 0.23, 95% CI: 0.1-0.7), while intravenous lines were associated with mixed delirium (OR 2.9, 95% CI: 1.2-6.9). CONCLUSIONS: The study shows that hypoactive delirium is the most common subtype among hospitalized older patients. Specific clinical features were associated with different delirium subtypes. The use of standardized instruments can help to characterize the phenomenology of different motor subtypes of delirium.

"Delirium Day": a nationwide point prevalence study of delirium in older hospitalized patients using an easy standardized diagnostic tool.

BACKGROUND: To date, delirium prevalence in adult acute hospital populations has been estimated generally from pooled findings of single-center studies and/or among specific patient populations. Furthermore, the number of participants in these studies has not exceeded a few hundred. To overcome these limitations, we have determined, in a multicenter study, the prevalence of delirium over a single day among a large population of patients admitted to acute and rehabilitation hospital wards in Italy. METHODS: This is a point prevalence study (called "Delirium Day") including 1867 older patients (aged 65 years or more) across 108 acute and 12 rehabilitation wards in Italian hospitals. Delirium was assessed on the same day in all patients using the 4AT, a validated and briefly administered tool which does not require training. We also collected data regarding motoric subtypes of delirium, functional and nutritional status, dementia, comorbidity, medications, feeding tubes, peripheral venous and urinary catheters, and physical restraints. RESULTS: The mean sample age was 82.0 ± 7.5 years (58 % female). Overall, 429 patients (22.9 %) had delirium. Hypoactive was the commonest subtype (132/344 patients, 38.5 %), followed by mixed, hyperactive, and nonmotoric delirium. The prevalence was highest in Neurology (28.5 %) and Geriatrics (24.7 %), lowest in Rehabilitation (14.0 %), and intermediate in Orthopedic (20.6 %) and Internal Medicine wards (21.4 %). In a multivariable logistic regression, age (odds ratio [OR] 1.03, 95 % confidence interval [CI] 1.01-1.05), Activities of Daily Living dependence (OR 1.19, 95 % CI 1.12-1.27), dementia (OR 3.25, 95 % CI 2.41-4.38), malnutrition (OR 2.01, 95 % CI 1.29-3.14), and use of antipsychotics (OR 2.03, 95 % CI 1.45-2.82), feeding tubes (OR 2.51, 95 % CI 1.11-5.66), peripheral venous catheters (OR 1.41, 95 % CI 1.06-1.87), urinary catheters (OR 1.73, 95 % CI 1.30-2.29), and physical restraints (OR 1.84, 95 % CI 1.40-2.40) were associated with delirium. Admission to Neurology wards was also associated with delirium (OR 2.00, 95 % CI 1.29-3.14), while admission to other settings was not. CONCLUSIONS: Delirium occurred in more than one out of five patients in acute and rehabilitation hospital wards. Prevalence was highest in Neurology and lowest in Rehabilitation divisions. The "Delirium Day" project might become a useful method to assess delirium across hospital settings and a benchmarking platform for future surveys.

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.

Sarcopenia and malnutrition in acutely ill hospitalized elderly: Prevalence and outcomes.

BACKGROUND & AIMS: Data about the prevalence of sarcopenia among hospitalized patients is lacking and it is unclear whether the diagnostic criteria commonly used in community-dwellers is applicable in acutely ill subjects. The aims of this report are: (i) to assess the prevalence of sarcopenia among hospitalized patients; (ii) to assess whether the European Working Group on Sarcopenia in Older People (EWGSOP) criteria are applicable in an acute care setting; and (iii) to assess the mortality rate at 3 months. METHODS: 103 patients admitted to the Acute Geriatric Clinic were enrolled. Inclusion criteria were: age ≥65 years and malnutrition or risk of malnutrition, according to the Mini Nutritional Assessment Short Form. Sarcopenia was diagnosed using the EWGSOP criteria by means of bioimpedance analysis, handgrip strength and gait speed, within 72 h of admission. Information on deaths was obtained by telephone interview at 3 months following discharge. RESULTS: Sarcopenia was diagnosed in 22 patients (21.4%). Twenty-three patients (22.3%) were not able to perform the gait speed and/or the handgrip strength because bedridden or requiring intensive treatments. In this group, a definite diagnosis of sarcopenia was not possible, lacking at least one EWGSOP criteria. Eleven (10.7%) patients died within the 3 months post-discharge period. Kaplan-Meier survival curves showed that sarcopenic patients died significantly more frequently than others (log-rank p ≤ 0.001). CONCLUSIONS: In a population of hospitalized elderly malnourished or at risk of malnutrition, sarcopenia is highly prevalent and associated with an increased risk to die in the short-term. Furthermore, the EWGSOP criteria cannot be satisfactorily applied in a relevant proportion of patients.

Geriatric multidimensional assessment for elderly patients with acute respiratory diseases.

The case of an 87-year-old woman who falls at home and is admitted to the Emergency Department of an acute hospital with delirium exemplify a common situation that physicians face in their everyday clinical practice. We describe the typical context of frailty in which acute illnesses frequently present in frail elderly patients and, in particular, the relationship between comorbidity, disability and frailty. We also report the current knowledge about frailty theories and we focus on the "atypical" presentation of many acute illnesses. Major attention is devoted on delirium and on mobility impairment, two of the most common atypical symptoms of elderly frail subjects. Finally we describe the evidence on the comprehensive geriatric assessment, i.e., the method that is required to identify and understand the ultimate needs of elderly complex subjects.

The sequential organ failure assessment score predicts 30-day mortality in a geriatric acute care setting.

BACKGROUND: Several tools to predict patients' survival have been proposed in medical wards, though they are often time consuming and difficult to apply. The Sequential Organ Failure Assessment (SOFA) is a promising tool that has been validated in intensive care units but never in acute medical wards. The aim of this study was to assess whether the SOFA score predicts short-term (30 days) mortality in a population of elderly patients admitted to a geriatric ward. METHODS: This prospective observational cohort study was carried out in a Geriatric Clinic of an Italian teaching hospital. Among 359 patients consecutively and firstly admitted between January and April 2012, we considered eligible those (n = 314) directly admitted from the emergency department. Demographic, functional, and clinical variables were collected. The SOFA score was measured on admission (SOFA-admission) and 48 hours later (SOFA-48h). The vital status of participants was assessed over the 30 days following discharge. RESULTS: Patients who died at 1-month follow-up were prevalently men, more comorbid, disabled, and undernourished and had higher SOFA scores on admission and at 48 hours than their counterparts. Among all potential predictors of 1-month mortality, the SOFA-48h score was the best, with a score greater than 4 significantly increasing the risk to die during hospitalization or in the 30 days following discharge (odds ratio = 7.030; 95% confidence interval = 3.982-12.409). CONCLUSIONS: The SOFA score, a user-friendly tool used in intensive care units to estimate prognosis, is able to predict 1-month mortality also in patients admitted to an acute geriatric setting.

The Italian version of the Glaucoma Symptom Scale Questionnaire: translation, validation, and reliability.

PURPOSE: To validate the Italian version of the Glaucoma Symptom Scale (GSS) Questionnaire and its symptoms and function subscales. METHODS: This transversal validation study enrolled nonhospitalized patients with glaucoma, and a reference sample of patients without eye diseases. Eligible participants had to be cognitively able to respond to a health status interview. The Italian self-administered versions of the 25-item National Eye Institute-Visual Function Questionnaire and the GSS Questionnaire were administered to all participants. Reliability and validity of the Italian translation of the GSS Questionnaire were tested using standard statistical methods for questionnaire validation. RESULTS: Ninety-seven patients were enrolled. Cronbach α coefficient ranged from 0.72 to 0.92 across subscales and eyes. Test-retest stability was >85% for each subscale and eye. The control group of participants had better scale scores across all dimensions of vision-targeted health-related quality of life captured by the GSS Questionnaire (P<0.05) and there were good correlations between responses GSS Questionnaire subscales and analogous domains of the 25-item National Eye Institute-Visual Function Questionnaire. CONCLUSIONS: The Italian version of the GSS Questionnaire has good validity, discriminatory power, internal consistence and reliability, showing psychometric properties comparable with those of the English version, and can therefore be used in clinical research as a specific measure of vision-related quality of life in Italian-speaking patients with ocular hypertension or glaucoma.