Emergency department: risk stratification in the elderly

Background & aims. The older adults have very frequent access to the Emergency Department (ED). The aim of this study is to explore the ability of some geriatric screening tools validated for the ED to predict outcomes (mortality, hospitalization, ED readmission and institutional-ization) at 6 months. Methods. Older adults consecutively admitted to Cagliari University’s ED between May and December of 2017 were enrolled. In ED older patients were screened with three tools: Identification of Seniors at Risk tool (ISAR); Triage Risk Screening Tool (TRST); International Resident Assessment Instrument Emergency Department Screener (InterRAI ED Screener). At 6 months patients were contacted by phone to verify: mortality, ED readmission, hospital admission, and institutionalization. Results. Of the 421 patients (median age 77, Interquartile Range 71-83; 55.8% women) enrolled, 72.4% were positive at the ISAR, 50.1% at the TRST; moreover 44.9% of enrolled subjects needed a urgent geriatric evaluation at the InterRAI ED Screener. The dead subjects had ISAR, TRST and InterRAI ED Screener with greater severity compared to the alive ones. The ISAR and the TRST were also more severe in subjects who had ED readmission, while those hospitalized, in addition to the ISAR, had the more severe Inter-RAI ED Screener. However, applying stepwise logistic regression, of the three tools used, only the ISAR was a predictor for hospitalization (OR = 1.23; CI = 1.03-1.48; P = 0.02; AUC = 0.63). Conclusions. The association of ISAR and InterRAI ED Screener may be useful in ED to intercept both critical issues typical of the elderly, and the need and priority of the geriatric evaluation

Cardiac function in borderline hypothyroidism: a study by pulsed wave tissue Doppler imaging

Objective: In subclinical hypothyroidism (SH), impaired diastolic function has been documented at rest and on effort, while systolic dysfunction has only been assessed on effort. Design: The aim of the present study was: (a) to further assess systolic function at rest in SH; and (b) to ascertain whether cardiac dysfunction could precede TSH increase in euthyroid patients with a high risk of developing SH. Methods: We studied 32 patients with classical Hashimoto's thyroiditis (22 with increased serum TSH (> 3 mU/ml – group A), and 10 with normal serum TSH (< 3 mU/ml – group B)); a third group (C), which included 13 healthy controls. All subjects underwent pulsed wave tissue Doppler imaging (PWTDI) to accurately quantify the global and regional left ventricular function. Results: When compared with group C, PWTDI indices showed that in both groups A and B there was a significant impairment of systolic ejection (P < 0.001 and P < 0.05, respectively), a delay in diastolic relaxation (P < 0.001 and P < 0.05, respectively) and a decrease in the compliance to the ventricular filling (P < 0.05). Several significant correlations were found between PWTDI parameters and serum-free T3 and T4 and TSH concentrations. Conclusion: PWTDI is a sensitive technique that allows detection of both diastolic and systolic abnormalities, not only in patients with SH, but also in euthyroid subjects with a high risk of developing thyroid failure. Futhermore, the significant correlations of several PWTDI indices with serum FT3 and TSH concentrations strongly support the concept of a continuum spectrum of a slight thyroid failure in autoimmune thyroiditis extending to subjects with serum TSH still within the normal range

&quot;Delirium Day&quot;: 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

"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 \ub1 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

A Reasoned Comparison between Two Hydrodynamic Models: Delft3D-Flow and ROMS (Regional Oceanic Modelling System)

Useful information, such as water levels, currents, salinity and temperature dynamics in water bodies, are obtained through numerical models in order to pursue scientific research or consultancy. Model validation dates back long ago, since such models started to be developed in the 1960s. Despite their usefulness and reliability in complex situations, some issues related to well-known benchmarks are still present. This work aims to analyse in detail the behaviour of the velocity profile, vertical eddy viscosity and tangential stresses at the bed in two cases of free surface flows; namely: uniform flow in an inclined rectangular channel and a wind-induced circulation in a closed basin. Computational results strongly depend on the turbulence closure model employed and a reasoned comparison is necessary to highlight possible improvements of these models. The strong differences that arise are deeply analysed in this work

Cardiac effects of L-thyroxine administration in borderline hypothyroidism

Design: To assess whether and to what extent administration of L-T4 is able to modify systolic and diastolic function in patients with subclinical hypothyroidism and in subjects with autoimmune thyroiditis and normal serum TSH. Methods: We studied 26 patients with classical Hashimoto's thyroiditis [18 with increased serum TSH (N3 mU/ml — Group A), and 8 with normal serum TSH (b3 mU/ml) — Group B]; a third group (C) included 13 healthy controls. All subjects underwent Pulsed Wave Tissue Doppler Imaging (PWTDI) to accurately quantify the global and regional left ventricular function. Results: In both groups A and B we confirmed a significant impairment of systolic ejection ( pb0.001 and pb0.05, respectively), a delay in diastolic relaxation ( pb0.001 and pb0.05, respectively) and a decrease in the compliance to the ventricular filling ( pb0.05). Administration of 50 μg/day of L-T4 produced a progressive reduction of serum TSH (within the normal range) and normalization of all PWTDI parameters, which began after 6 months and finished after 12 months. Conclusion: Our data confirm previous evidence that subclinical hypothyroidism is associated with a cardiac dysfunction, even when this is very mild (i.e. with serum TSH still comprised in the normal range), and show that these abnormalities are reversible with L-T4 replacement therapy

Cardiac function in borderline hypothyroidism: a study by pulsed wave tissue Doppler imaging

Objective: In subclinical hypothyroidism (SH), impaired diastolic function has been documented at rest and on effort, while systolic dysfunction has only been assessed on effort. Design: The aim of the present study was: (a) to further assess systolic function at rest in SH; and (b) to ascertain whether cardiac dysfunction could precede TSH increase in euthyroid patients with a high risk of developing SH. Methods: We studied 32 patients with classical Hashimoto’s thyroiditis (22 with increased serum TSH (.3 mU/ml – group A), and 10 with normal serum TSH (,3 mU/ml – group B)); a third group (C), which included 13 healthy controls. All subjects underwent pulsed wave tissue Doppler imaging (PWTDI) to accurately quantify the global and regional left ventricular function. Results: When compared with group C, PWTDI indices showed that in both groups A and B there was a significant impairment of systolic ejection (P , 0.001 and P , 0.05, respectively), a delay in diastolic relaxation (P , 0.001 and P , 0.05, respectively) and a decrease in the compliance to the ventricular filling (P , 0.05). Several significant correlations were found between PWTDI parameters and serum-free T3 and T4 and TSH concentrations. Conclusion: PWTDI is a sensitive technique that allows detection of both diastolic and systolic abnormalities, not only in patients with SH, but also in euthyroid subjects with a high risk of developing thyroid failure. Futhermore, the significant correlations of several PWTDI indices with serum FT3 and TSH concentrations strongly support the concept of a continuum spectrum of a slight thyroid failure in autoimmune thyroiditis extending to subjects with serum TSH still within the normal range

Nutritional and psycho-functional status in elderly patients with Alzheimer’s disease

Objectives: Analysis of variations of nutritional status in relation to psycho-functional conditions in elderly patients with mild to moderate Alzheimer's disease (AD) by means of bioelectrical impedance vector analysis (BIVA). Design: Cross-sectional study. Setting: Alzheimer Center, SS. Trinita Hospital, Cagliari (Italy). Participants: 83 free-living patients (29 men, 54 women) with mild-moderate Alzheimer's disease, aged 66 to 96 years, and 91 age-matched controls (37 men and 54 women). Measurements: Nutritional status was evaluated by anthropometry (weight, height, waist and upper arm circumferences, triceps skinfold; body mass index, BMI; arm muscle area, AMA); Mini Nutritional Assessment, MNAR; bioelectrical impedance vector analysis, BIVA. Psycho-functional status was assessed by the Mini Mental State Examination (MMSE), Geriatric Depression Scale (GDS), Activities of Daily Living (ADL), and Instrumental Activities of Daily Living (IADL). Results: Compared to the control groups, patients with Alzheimer's disease had a worse psycho-functional and nutritional status. BIVA detected lower body cell mass in Alzheimer's patients with respect to controls (men: T2= 23.4; women: T2=27.3; p<0.01), as well as in the female patients with lower levels of IADL and MMSE (respectively, T2= 8.0; T2=7.4; p<0.05). In patients with AD, a worse psycho-functional status was associated with obesity. Conclusion: The psycho-functional decline of patients with AD is related to body composition variations, with a relative increase of fat mass with respect to the muscle component. The BIVA technique distinguished patients from controls and patients with different levels of cognitive decline. Therefore, it is a suitable tool for the screening and monitoring of nutritional status in Alzheimer's disease

Associations between conflictual relationships, psychopathology, and the use of psychotropic drugs among older people living in residential facilities

BACKGROUND: Psychiatric symptoms and conflictual relationships (CR) may negatively affect the delivery of care in residential facilities (RF). This study aims to analyze neuropsychiatric symptoms, their correlations with CR among older people living in RF, and their associations with the prescription of psychotropic drugs. METHODS: A total of 1215 RF residents in five Italian regions were selected for this cross-sectional study. Psychiatric symptoms and CR were assessed with the Neuropsychiatric Inventory and the Resident Assessment Instrument, respectively. Associations between Neuropsychiatric Inventory items, CR, and the use of psychotropic drugs were tested via multiple logistic regressions. RESULTS: About half (52.7%) of the RF residents experienced one or more clinically relevant neuropsychiatric symptoms. At least one category of CR was reported for 223 residents (19%). Although reciprocal associations were found between different categories of CR, only conflictuality with other residents was associated with the use of antipsychotics (odds ratio (OR) = 2.12). Significant associations were found with irritability (with staff: OR = 2.35; with relatives: OR = 3.09), aberrant motor behaviour (with staff: OR = 2.02), and elation (with relatives: OR = 10.55). CONCLUSIONS: Neuropsychiatric symptoms and CR are common among RF residents and are reciprocally associated. Further research with longitudinal design is needed to better understand this relationship. KEYWORDS: aged; conflictual relationships; psychopathological symptoms; psychotropic drugs; residential facilitie