Walter De Alfieri

Prognostic Stratification of Older Persons Based on Simple Administrative Data: Development and Validation of the “Silver Code,” To Be Used in Emergency Department Triage

BACKGROUND Prognostic stratification of older patients with complex medical problems among those who access the emergency department (ED) may improve the effectiveness of geriatric interventions. Whether such targeting can be performed through simple administrative data is unknown. METHODS We examined the discharge records for 10,913 patients aged 75 years or older admitted during 2005 to the ED of all public hospitals in Florence, Italy. Using information on demographics, drug treatment, previous hospital admissions, and discharge diagnoses, we developed a 1-year mortality prognostic index. The predictive validity of this index was tested in a subsample of patients independent of the subsample used for its original development. Finally, we tested whether patients stratified by the prognostic index had different mortality when admitted to a geriatrics compared with an internal medicine ward. RESULTS In the validation subsample, patients with scores of 4-6, 7-10, and 11+ compared with those with scores less than 4 had hazard ratios (95% confidence interval) for 1-year mortality of, respectively, 1.5 (1.3-1.7), 2.2 (1.3-1.7), and 3.0 (2.6-3.4). Patients in the worse prognostic stratum experienced 33% higher mortality when admitted to an internal medicine compared with a geriatrics ward, although mortality was not significantly affected by the type of ward of admission in all other risk strata. CONCLUSIONS Simple administrative data provide prognostic information on long-term mortality in older patients hospitalized via ED. Patients with worse prognostic index scores appear to benefit from admission in a geriatrics compared with an internal medicine ward.

Disease severity and health-related quality of life across different chronic conditions.

Measurements of health‐related quality of life (HRQL) are an essential component in overall assessment of health status, particularly in older patients. Nevertheless, how measures of HRQL relate to measures of disease severity is largely unexplored. This study was carried out to explore the relationship between a measure of HRQL and measures of severity of ischemic stroke, Parkinsons diseases (PD), or chronic coronary heart disease (CHD).

Cardiovascular remodeling is greater in isolated systolic hypertension than in diastolic hypertension in older adults: the Insufficienza Cardiaca negli Anziani Residenti (ICARE) a Dicomano Study ☆

OBJECTIVE We investigated cardiac and vascular remodeling in an unselected older population with either diastolic hypertension (HTN) or isolated systolic hypertension (ISH). BACKGROUND Isolated systolic hypertension accounts for a substantial proportion of hypertension in individuals older than 65 years and is strongly associated with an increased risk of cardiac and cerebrovascular events. The exact mechanisms underlying the increased risk associated with ISH and elevated pulse pressure (PP), in comparison with HTN, have not been extensively investigated. METHODS Community-dwelling residents age >/=65 years in a small town in Italy (Dicomano) were enrolled. Untreated subjects considered in this study included 173 normotensive subjects (blood pressure [BP] <140/90 mm Hg), 95 subjects with HTN (diastolic BP >/=90 mm Hg), and 43 subjects with ISH (BP >/=160/<90 mm Hg). All subjects underwent extensive clinical examination, echocardiography, carotid ultrasonography, and carotid applanation tonometry. RESULTS Subjects with ISH had higher left ventricular (LV) mass, which was independently related to PP but not to systolic or mean pressures. Both carotid wall cross-sectional area and vascular stiffness were greater in ISH patients than in HTN and normal subjects and were independently related to PP but not to systolic BP. In addition, ISH was associated with a higher prevalence of carotid plaque and more extensive carotid atherosclerosis. CONCLUSIONS In our community-based elderly population, individuals with ISH had higher prevalences of LV hypertrophy and carotid atherosclerosis than subjects with HTN despite lower mean BP. These findings provide potential pathophysiologic mechanisms underlying the associations of ISH and PP with increased risk of cardiovascular morbidity and mortality.

Hemodynamic and electrocardiographic effects of fructose-1,6-diphosphate in acute myocardial infarction

Acute hemodynamic and electrocardiographic effects of fructose-1,6-diphosphate (FDP), an agent that is supposed to restore anaerobic glycolytic flux in the ischemic myocardium, were studied in 40 patients with acute myocardial infarction who were grouped into 4 subsets: subset 1, normal (15 mm Hg or less) pulmonary artery (PA) wedge pressure and normal (35 g-m/m2 or greater) left ventricular (LV) stroke work index; subset 2, elevated (more than 15 mm Hg) PA wedge pressure and normal LV stroke work index; subset 3, normal PA wedge pressure and reduced (less than 35 g-m/m2) LV stroke work index; subset 4, elevated PA wedge pressure and LV stroke work index moderately reduced to a range between 16 and 34 g-m/m2. Patients were randomized into an FDP (250 mg/kg body weight in isotonic saline solution intravenously in 20 minutes) and into a placebo group. Each subset contained 5 FDP- and 5 placebo-treated patients. After basal measurements, hemodynamic measurements were reassessed at 60, 90 and 120 minutes from the infusions, while a standard 12-lead electrocardiogram was recorded in the basal state and 120 minutes after infusion. Nonsignificant hemodynamic change was observed in the placebo subsets, and FDP failed to exert any effect in subsets 1, 2 and 3. A 24% (p less than 0.02) increase in cardiac index occurred 60 minutes after FDP in subset 4. LV stroke work index also increased, while PA wedge pressure remained unchanged.(ABSTRACT TRUNCATED AT 250 WORDS)

Heart Failure in Community-Dwelling Older Persons: Aims, Design and Adherence Rate of the ICARe Dicomano Project: An Epidemiologic Study

BACKGROUND: The prevalence of heart failure (HF) increases with age, and HF is a major cause of disability and mortality in older persons. Detection of HF in epidemiological studies has relied on criteria validated only in young and middle‐age adults, and, therefore, may prove inadequate in older subjects, because they do not take into account the pathophysiologic and clinical peculiarities of HF in old age. Thus, the true prevalence of HF in the older general population remains uncertain and has probably been underestimated in previous studies. Moreover, the mechanism and the extent by which HF hinders physical functioning in older people has not been fully elucidated.

Functional Recovery of Elderly Patients Hospitalized in Geriatric and General Medicine Units. The PROgetto DImissioni in GEriatria Study

OBJECTIVES: To investigate the characteristics of patients who regain function during hospitalization and the differences in terms of functional outcomes between patients admitted to geriatric and general medicine units.

Hemodynamic effects of digoxin in acute myocardial infarction in man: a randomized controlled trial

Hemodynamic effects of digoxin in acute myocardial infarction (AMI) have been acknowledged to depend on the basal cardiocirculatory state. In the present study, the effects of digoxin in patients with AMI were evaluated in four hemodynamic subsets, based on the relationship between mean pulmonary capillary wedge pressure (PCWP, in mm Hg) and left ventricular stroke work index (LVSWI, in g-m/m2): subset 1: normal (less than or equal to 15 mm Hg) PCWP and normal (greater than or equal to 35 g-m/m2) LVSWI; subset 2: elevated (greater than 15 mm Hg) PCWP and normal LVSWI; subset 3: reduced (less than 35 g-m/m2) LVSWI and normal PCWP; and subset 4: elevated PCWP and LVSWI moderately reduced to a range between 16 and 34 g-m/m2. Forty patients were admitted to the study and were randomly assigned to one of two groups in each subset: control group (19 patients) and treated group (21 patients). Five patients were randomized into each of the subsets 2, 3, and 4 in both the control and treated groups, while in subset 1 there were four control and six digoxin-treated patients. Control patients were administered a placebo saline solution and digoxin-treated patients received 0.50 mg of the drug intravenously in 20 minutes. The effects of the placebo and of the drug were evaluated at 30, 60, and 90 minutes from the end of the infusion. Hemodynamic data did not vary in the control group, and digoxin did not exert any relevant effect in subsets 1 and 2. After drug infusion, cardiac index (Cl, in L/min/m2) significantly increased in subset 3 patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Thyroid Hormones as Predictors of Short- and Long-term Mortality in Very Old Hospitalized Patients

BACKGROUND Although extensively investigated, the prognostic role of thyroid hormone abnormalities in older participants remains uncertain. We investigated the relationship between thyroid hormones and mortality during hospitalization and in a prolonged follow-up in frail older patients. METHODS A nonconcurrent cohort study was conducted by enrolling 450 participants hospitalized for an acute disease, who were classified into four groups (euthyroidism, hypothyroidism, hyperthyroidism, and low triiodothyronine [T3] syndrome), according to clinical and laboratory data. Multidimensional geriatric assessment variables were considered in order to identify short- and long-term predictors of death. RESULTS Participants were very old (mean age: 84 years) and frail, as indicated by severely impaired functional status, extensive comorbidity, high prevalence of dementia, and hospital mortality (8%). Prevalence of any thyroid dysfunction was 40.7%; 32% of participants had low T3 syndrome, which was associated with an excess hospital mortality risk (odds ratio: 2.7, 95% confidence interval [CI]: 1.1-6.5; p = .025), adjusted for demographic, clinical, functional, and laboratory data. Conversely, long-term mortality was unrelated to low T3 syndrome. In euthyroid participants, increasing levels of free thyroxine (FT4) were associated with a slightly greater mortality (hazard ratio, CI: 2.12, 0.99-4.54; p = .053) in adjusted Cox regression models. CONCLUSIONS This observational study on a cohort of very old, frail hospitalized patients gives support to the independent prognostic short-term, but not long-term, role of low T3 syndrome. Moreover, in older euthyroid participants, increasing levels of FT4 are a weak marker of poorer long-term survival. Thyroid hormones may help monitor changes in general health status and predict short- and long-term clinical outcomes in very old, frail patients.

Acute functional decline before hospitalization in older patients.

Acute diseases and related hospitalization are crucial events in the disabling process of elderly individuals. Most of the functional decline occurs in the few days before hospitalization, as a result of acute diseases in vulnerable patients. The aim of the present study was to identify determinants of prehospital components of functional decline.

THROUGH THE LOOKING GLASS AND WHAT FRAILTY FOUND THERE: LOOKING FOR RESILIENCE IN OLDER ADULTS

To the Editor: The challenges of an aging populations is, without doubt, obtaining an increase in life expectancy accompanied by a concurrent postponement of functional limitations and disability. This is based on the opinion that the aging process is modifiable using technological, methodological, and medical developments. In recent years, geriatric research, in the oldest old, has focused attention in definition and recognition of frailty in order to promote preventive and interventional measures. It is well established that appropriate measures can probably positively modify adverse outcomes in frail older adults, but another critical topic in geriatric medicine should be to clarify which elderly persons in critical condition should have therapy. The decision-making process regarding what should be done in an emergency, in rationalizing invasive treatments, in providing better-quality end-of-life care, is not well established yet in patients aged 80 and older. It is necessary to personalize medical treatment, adapting interventions to the real capacity of the patients to respond in a cost-effective manner. Most healthcare practitioners probably have an opinion on this matter. Even if geriatricians lack training in analyzing the elements that would affect their decisions, they usually address these themes every day, whether initiating a demanding treatment or in confronting the possibility of death. The knowledge that some of them can have a satisfactory response to treatment, regardless of age, influences behavior in front of severely disabled, comorbid elderly patients suffering from acute, severe, unstable diseases with high risks of complications and death. Geriatricians seemed to know the amount of change the patient can undergo while retaining the same controls on function and structure. In this sense, cognitive and functional effect of acute illness severity are not usually taken into account when withholding life-sustaining treatment in hospitalized older adults, and symptoms, rather than the number of coexisting diseases, represent useful indicators of disability burden in medically complex patients. In psychology, resilience is the positive capacity of people to cope with stress and catastrophe; in technology, resilience is the property of a material to absorb energy when it is deformed elastically and then, upon unloading, to have this energy recovered (the opposite of frailty). Encountering significant difficult circumstances, resilience can be described by viewing constant competence under stress, recovery from a dramatic event, favorable outcomes regardless of high-risk status, and ability to build and increase the capacity for learning and adaptation. All of these things work together to prevent debilitating behaviors. Human life, as with any natural system, is inherently resilient, but just as its capacity to cope with disturbance can be degraded, so can it be enhanced. For these reasons, we suggested the possibility of studying biological resilience in elderly people, when a positive response to usual, unextraordinary measures overwhelms vulnerability, which pools any negative and ineffective responses to challenging conditions. At the onset of research on psychological resilience, researchers have been devoted to discovering the protective factors that explain people’s adaptation to adverse conditions; the focus of empirical work then has been shifted to understanding the underlying protective processes. In geriatrics, researchers should endeavor to uncover how some protective factors (genetic, demographic, environmental, sex-linked, social, humoral, psychological, functional) may contribute to positive outcomes. If information can be found, it can be used to predict resilience and help evaluate the situation. Moreover, other practical clinical implications of the present hypothesis should be the determination of a stopping criterion to determine the dose of any therapy for each patient and the recognition of the threshold above which most functions improve spontaneously or the threshold at which therapy may be stopped without adverse effect, or under which it is ‘‘in vain.’’ Shifting research from a negative concern (frailty) to a positive one (resilience) might achieve relevant effects, also because restoring a system to its previous state can be complex, expensive, and sometimes even impossible, whereas a resilient system can withstand shocks and rebuild itself when necessary. Resilience is the added capacity of humans to anticipate and plan for the future. At any age.