Predictors of In-Hospital Mortality in Older Inpatients with Suspected Infection.

OBJECTIVES: To determine the rate and predictors of death in older individuals with suspected infection at any time during hospital stay in a geriatric acute ward and the prognostic ability of different tools [quick Sequential (Sepsis-related) Organ Failure Assessment (qSOFA), Modified and National Early Warning Scores (MEWS) and (NEWS)] in such population. DESIGN: Prospective observational single-center cohort study. SETTING AND PARTICIPANTS: Among patients admitted to an acute geriatric unit of an Italian University Hospital with at least 1 sepsis risk factor, all subjects with suspected infection at admission or during hospital stay (defined as antibiotic prescription and associated culture test) were considered. METHODS: A geriatric assessment including comorbidity and social, functional, and cognitive status was performed for each patient. Clinical parameters were evaluated at least twice daily throughout hospital stay; qSOFA, MEWS, and NEWS were derived, with positive cutoffs set at ≥2, ≥5, and ≥7, respectively. RESULTS: Among 305 older inpatients (median age 86.0 years, 49.2% female), 21% died during hospital stay. Sepsis was diagnosed in 31.8% of the overall sample and in 64.1% of deceased patients. Deceased patients showed a significantly higher prevalence of prior institutionalization, functional dependence, cognitive impairment, and multimorbidity. The prognostic accuracy of the qSOFA score at infection onset was only fair (area under the receiver operating characteristic curve 0.72; 95% CI, 0.65-0.79, P < .001) and comparable with that of MEWS and NEWS. After multivariable analysis, in-hospital death was positively associated with male sex [odds ratio (OR), 2.11; 95% CI, 1.01-4.44; P = .048] and abnormal white blood cells count (OR, 4.93; 95% CI, 2.36-10.29; P < .001), platelet count (OR, 2.61; 95% CI, 1.10-6.16; P = .029) and serum creatinine (OR, 2.70; 95% CI, 1.30-5.61; P = .008), along with any of the score considered, and negatively associated with autonomy in instrumental activities (OR, 0.78; 95% CI, 0.68-0.90; P < .001). CONCLUSIONS: Prognosis in older inpatients with infection or sepsis appears to be determined both by the geriatric characteristics and by the severity of the acute event, expressed by recommended tools and blood test results.

Comparison of Diagnostic Accuracies of qSOFA, NEWS, and MEWS to Identify Sepsis in Older Inpatients With Suspected Infection.

OBJECTIVES: To determine and compare the accuracies of the quick Sequential (Sepsis-related) Organ Failure Assessment (qSOFA) and Modified and National Early Warning Scores (NEWS and MEWS) to identify sepsis in older inpatients with suspected infection. DESIGN: Prospective diagnostic accuracy study. SETTING AND PARTICIPANTS: Patients admitted to an acute geriatric unit of an Italian University Hospital with at least one sepsis risk factor and suspected infection defined as antibiotic prescription and associated culture test during hospital stay. METHODS: Sepsis diagnosis was defined as the presence on discharge documents of International Classification of Diseases, Ninth revision, Clinical Modification codes for severe sepsis, septic shock, or for infection and acute organ disfunction. For each patient, clinical parameters were evaluated at least twice daily throughout hospital stay; qSOFA, NEWS, and MEWS were derived, and worst scores recorded. Positive cutoffs were set at ≥2, ≥7, and ≥5, respectively. Sensitivity, specificity, positive and negative predictive values (PPV and NPV, respectively), and positive and negative likelihood ratios, as well as areas under the receiver operating characteristic curve (AUROCs) were calculated. RESULTS: Among 230 geriatric patients with suspected infection at risk for sepsis (median age 86 years, 49% women), 30.9% had a sepsis diagnosis. A qSOFA ≥2 was recorded in 111 (48.3%) patients, a MEWS ≥5 in 65 (28.3%), and a NEWS ≥7 in 115 (50.0%). The qSOFA showed the highest sensitivity [81.7%, 95% confidence interval (CI) 71.7%-89.5%], but low specificity (66.7%, 95% CI 59.1%-73.7%), resulting in a high NPV (89.1%; 95% CI 82.7%-93.8%) and poor PPV (52.3%, 95% CI 43.0%-61.4%). The AUROC for qSOFA was 0.76 (95% CI 0.69-0.83), comparable with that of NEWS (0.74, 95% CI 0.67-0.81, P = .44), but significantly higher than that of MEWS (0.70, 95% CI 0.63-0.77, P = .04). CONCLUSIONS AND IMPLICATIONS: Repeated qSOFA determinations are useful to rule out sepsis in geriatric inpatients with suspected infection, but poorly support its diagnosis due to low specificity. More complex MEWS and NEWS do not perform better. Implementation of clinical scores to reliably identify sepsis in older patients is urgently needed.

[How much frailty is important in cardiology?] / Quanto è rilevante la fragilità in cardiologia?

Prevalence and incidence of cardiovascular diseases increase dramatically with advancing age, and older subjects account for the vast majority of patients seeking care either for acute and chronic cardiovascular disorders. In the same time, availability and improvements in drugs and devices, and innovative techniques in interventional cardiology and heart surgery procedures, increased as well, posing crucial challenges in clinical decision-making mainly in older people. Elderly subjects represent a very heterogeneous population and the interplay between underlying physiological change, chronic disease and multimorbidity can result in health states in older ages that are not fully captured by traditional disease classifications and that are often missing in disease-based assessments of health. Geriatric syndromes have been widely recognized as an essential determinant of health status and well-being of older people, although there is some debate as to what disorders these include. Foremost among the geriatric syndromes is frailty, which can be regarded as a progressive age-related deterioration in physiological systems that results in greater vulnerability to stressors and increased risk of adverse outcomes, including care dependence and death. This complexity of health states in older ages means that disease-based conceptualizations are inadequate proxies for health in an older person. Rather than the presence or absence of disease, the most important consideration for older subjects is likely to be their functioning. The Comprehensive Geriatric Assessment (CGA), which evaluates through the use of standardized scales several domains - including comorbidity, cognitive and mood disorders, functional abilities, nutritional status, sarcopenia and frailty - has been demonstrated to be a much better predictor of survival and other outcomes than the presence of diseases or even the extent of comorbidities. Therefore, physicians should be aware that age by itself is probably not the best criterion to rely on for challenging clinical decision-making in this setting. In this clinical context, it becomes mandatory that, beyond age-based decisions or an "eyeballing" perception of "frailty" or "vulnerability", standardized and valid measures aimed at selecting those patients who may potentially derive the greatest benefit from medical or interventional procedures are made available for daily clinical use.