"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

Declino cognitivo e stress ossidativo

Introduction. The pathogenesis of Alzheimer disease (AD) and mild cognitive impairment (MCI) is largely unknown. Several evidence document an involvement of oxidative stress in the development of these two diseases. Materials and methods. We studied patients older than 65 years who came to our Alzheimer evaluation unit between January and December 2008. Patients underwent accurate history taking and complete clinical examination, nutritional evaluation, cognitive tests, functional status evaluation and a dosage of plasma isoprostane and total antioxidant status. Results. We studied 66 subjects with a median age of 77.14 years, 34 men (51.5%) and 32 women (48.5%). The mean concentration of isoprostane in the three groups were: 34.21 pg/ml in controls, 41.54 pg/ml in MCI and 31.84 pg/ml in patients with AD. For the Total Antioxidant Status the mean for the three groups were: controls 2.19 mmol/l, MCI 2.60 mmol/l and AD 3.40 mmol/l (p = 0.002 AD/controlli, 0.041 AD/MCI). Conclusions. Our results are in agreement with other studies showing a reduction of antioxidants enzymatic and non enzymatic defenses in serum of Alzheimer and mild cognitive impairment patients

Quetiapina: un farmaco sicuro? Studio osservazionale in pazienti dementi con BPSD

Introduction: Behavioural and Psychological Symptoms of Dementia (BPSD) often occur in patients with dementia leading to a complex clinical course and a more difficult management of these subjects. Although a standardized therapy for these symptoms is not available, typical and atypical antipsychotics drugs are actually used for the treatment of these disturbs. Previous studies have demonstrated efficacy and safeness of these drugs and only few cardiovascular adverse events have been reported in patient treated with antipsychotics than in controls. Aim: Aim of this work was to evaluate the occurrence of cardiovascular adverse events such as blood pressure reduction and/or ECG alterations (cardiac frequency, PQ, QTc) in dementia patients with BPSD treated with quetiapine. Methods: 30 patients, 23 women and 7 men, aged from 71 to 97 years (average 85.17 ± 6.006 SD) in who diagnosis of dementia and BPSD was performed. Patients were examined with MMSE (Mini Mental State Examination) to evaluate cognitive impairment, with ADL (Activity of Daily Living) and IADL (Instrumental Activity of Daily Living) in order to analyze respectively simple daily activities and complex ones. Moreover, NPI (Neuropsychiatric Inventory) and NPI-D (Neuropsychiatric Inventory-Distress) were performed to check frequency and severity of BPSD and the associated caregiver’s distress. Electrolytes values (Na, K) and orthostatic and clinostatic blood pressure values were measured and ECG (cardiac frequency, PQ, QTc) was performed in each patients at the beginning of the therapy with Quetiapine (T0), after six months (T1) and after one year of treatment (T2). Conclusions: Our study resulted in an increase of NPI and NPI-D scores which stands for an improvement of BPSD in our patients and for a reduction of caregiver’s stress. On the other side, a statistically significant decrease in ADL score was found during the treatment, while no other important modifications of the analyzed parameters occurred. We conclude that the treatment with quetiapine didn’t cause cardiovascular adverse events such as blood pressure changes, ECG parameters alterations and electrolytes values modifications

IL CONSENSO INFORMATO NELLA CURA DEL PAZIENTE CON FRATTURA DEL FEMORE

Informed consent is fundamental in the process of care, except in case of urgent, lifesaving treatments. In Italy, the legal sources are the Italian Constitution, the numerous judgments of the courts and the current \u201cCodice di Deontologia medica\u201d. In clinical practice, as in the case of the elderly patient with hip fracture, the physician may encounter problems if the patient is incompetent and without legal representation

Health care for older people in Italy: The U.L.I.S.S.E. Project (Un link informatico sui servizi sanitari esistenti per l'anziano - a computerized network on health care services for older people).

Objectives: The U.L.I.S.S.E. study is aimed at describing older patients who are cared for in hospitals, home care or nursing homes in Italy. Design: The U.L.I.S.S.E. study is an observational multicenter prospective 1-year study. Setting: Overall, 23 acute geriatric or internal medicine hospital units, 11 home care services and 31 nursing homes participated in the study. Measurements: The patient\u2019s evaluation was performed using comprehensive geriatric assessment instruments, i.e. the interRAI Minimum Data Set, while data on service characteristics were recorded using ad-hoc designed questionnaires. Results: The older subjects who are in need of acute and long term care in Italy have similar characteristics: their mean age is higher than 80 years, they have a high level of disability in ADL, an important multimorbidity, and are treated with several drugs. The prevalence of cognitive impairment is particularly high in nursing homes, where almost 70% of residents suffer from it and 40% have severe cognitive impairment. On the other hand, there is a shortage of health care services, which are heterogeneous and fragmented. Conclusions: Health care services for older people in Italy are currently inadequate to manage the complexity of the older patients. An important effort should be undertaken to create a more integrated health care system

Health care for older people in Italy: The U.L.I.S.S.E. Project (Un link informatico sui servizi sanitari esistenti per l'anziano - a computerized network on health care services for older people)

Objectives: The U.L.I.S.S.E. study is aimed at describing older patients who are cared for in hospitals, home care or nursing homes in Italy. Design: The U.L.I.S.S.E. study is an observational multicenter prospective 1-year study. Setting: Overall, 23 acute geriatric or internal medicine hospital units, 11 home care services and 31 nursing homes participated in the study. Measurements: The patient\u2019s evaluation was performed using comprehensive geriatric assessment instruments, i.e. the interRAI Minimum Data Set, while data on service characteristics were recorded using ad-hoc designed questionnaires. Results: The older subjects who are in need of acute and long term care in Italy have similar characteristics: their mean age is higher than 80 years, they have a high level of disability in ADL, an important multimorbidity, and are treated with several drugs. The prevalence of cognitive impairment is particularly high in nursing homes, where almost 70% of residents suffer from it and 40% have severe cognitive impairment. On the other hand, there is a shortage of health care services, which are heterogeneous and fragmented. Conclusions: Health care services for older people in Italy are currently inadequate to manage the complexity of the older patients. An important effort should be undertaken to create a more integrated health care system

Correction to: Tocilizumab for patients with COVID-19 pneumonia. The single-arm TOCIVID-19 prospective trial (Journal of Translational Medicine, (2020), 18, 1, (405), 10.1186/s12967-020-02573-9)

Following publication of the original article [1] the authors identified that the collaborators of the TOCIVID-19 investigators, Italy were only available in the supplementary file. The original article has been updated so that the collaborators are correctly acknowledged. For clarity, all collaborators are listed in this correction article

Tocilizumab for patients with COVID-19 pneumonia. The single-arm TOCIVID-19 prospective trial

BackgroundTocilizumab blocks pro-inflammatory activity of interleukin-6 (IL-6), involved in pathogenesis of pneumonia the most frequent cause of death in COVID-19 patients.MethodsA multicenter, single-arm, hypothesis-driven trial was planned, according to a phase 2 design, to study the effect of tocilizumab on lethality rates at 14 and 30 days (co-primary endpoints, a priori expected rates being 20 and 35%, respectively). A further prospective cohort of patients, consecutively enrolled after the first cohort was accomplished, was used as a secondary validation dataset. The two cohorts were evaluated jointly in an exploratory multivariable logistic regression model to assess prognostic variables on survival.ResultsIn the primary intention-to-treat (ITT) phase 2 population, 180/301 (59.8%) subjects received tocilizumab, and 67 deaths were observed overall. Lethality rates were equal to 18.4% (97.5% CI: 13.6-24.0, P=0.52) and 22.4% (97.5% CI: 17.2-28.3, P<0.001) at 14 and 30 days, respectively. Lethality rates were lower in the validation dataset, that included 920 patients. No signal of specific drug toxicity was reported. In the exploratory multivariable logistic regression analysis, older age and lower PaO2/FiO2 ratio negatively affected survival, while the concurrent use of steroids was associated with greater survival. A statistically significant interaction was found between tocilizumab and respiratory support, suggesting that tocilizumab might be more effective in patients not requiring mechanical respiratory support at baseline.ConclusionsTocilizumab reduced lethality rate at 30 days compared with null hypothesis, without significant toxicity. Possibly, this effect could be limited to patients not requiring mechanical respiratory support at baseline.Registration EudraCT (2020-001110-38); clinicaltrials.gov (NCT04317092)