Cardiovascular morbidity and long term mortality associated with in hospital small increases of serum creatinine.

BACKGROUND: The cardiovascular risk associated with an increase in serum creatinine below the acute kidney injury (AKI) threshold, during hospitalization, has not been studied in depth. We assessed patients' features and outcomes associated with these changes. METHODS: Retrospective cohort study of 12,493 consecutive patients admitted to hospital throughout 12 months. We investigated the patients who had a small creatinine increase (SISCr) between 1.2 and <1.5 times the admission value, and tested the association of creatinine changes with the prevalence of cardiovascular disease (CVD). In a follow-up study, we assessed the all-cause mortality and its relationship with SISCr. RESULTS: Among patients with two or more creatinine measurements, 14.9% showed a SISCr. Older age, female gender and higher estimated glomerular filtration rate (eGFR) at admission were characteristics of these patients. The prevalence of CVD was 14.6% in patients with SISCr vs. 10.7% in those with stable creatinine (p < 0.001). SISCr was detected in 36, 26.6 and 18.9% of chronic heart failure (CHF), chronic ischemic heart disease (CIHD) and acute myocardial infarction (AMI) patients, respectively. The follow-up was 26.7 ± 10.6 months with 770 all-cause deaths. Serum creatinine increase above 20% was associated with a significant higher mortality compared to changes below 20%, adjusted hazard (HR) ratio 1.577 (p < 0.001). A higher risk was found associated with creatinine increases >1.5 times the baseline: HR 1.704 (p < 0.001). CONCLUSIONS: In hospitalized patients, increases in serum creatinine below the AKI threshold are associated with CHF, CIHD and long-term mortality.

Association of reduced kidney function with cardiovascular disease and mortality in elderly patients: comparison between the new Berlin initiative study (BIS1) and the MDRD study equations.

BACKGROUND: New creatinine based equations for estimating glomerular proposed for aged subjects have not been assessed in their association of reduced eGFR with cardiovascular (CV) morbidity or all cause (AC) mortality. PATIENTS: All subjects ≥70 years old (2998) who had been admitted to the hospital during a 12 month period were examined. METHODS: In a cohort study we applied the new Berlin Initiative Study (BIS1) equation. We compared the association of reduced eGFR estimated by BIS1 and MDRD equations, with cardiovascular (CV) disease and all cause (AC) mortality. RESULTS: eGFR was 57 ± 17 mL/min/1.73 m2 by MDRD and 71 ± 28 mL/min/1.73 m2 by BIS1 (P < 0.001). A diagnosis of CV disease was present in 947 patients. CV disease was associated with eGFR < 60 mL/min/1.73 m2 by both formulas: OR 1.179 (CI 1.001-1.390) for BIS1 and OR 1.440 (CI 1.223-1.696) for MDRD. In survival analysis a significant association of eGFR < 60 mL/min/1.73 m2 with AC mortality was found for both equations: MDRD (HR = 1.270, CI 1.111-1.453, P < 0.001), BIS1 (HR = 1.174, CI 1.031-1.338, P = 0.016). The analysis repeated with groups of age showed that the association of mortality with eGFRBIS1 < 60 mL/min/1.73 m2 was lost over 80 years. CONCLUSIONS: In patients >70, admitted to hospital, the implementation of the new BIS1 estimating equation does not modify the relationship, observed with the MDRD formula, of reduced GFR with CV disease or AC mortality.

Characteristics of the Relationship of Kidney Dysfunction with Cardiovascular Disease in High Risk Patients with Diabetes.

We aimed at comparing the relationship of reduced estimated glomerular filtration rate (eGFR) with cardiovascular disease (CVD) and mortality between high risk patients with and without type 2 diabetes mellitus (T2DM). The cross-sectional study evaluated 16,298 participants (1,627 T2DM) acutely admitted to hospital. The longitudinal study comprised 7,508 patients (673 with diabetes and 6,835 without). eGFR was categorized into 6 stages from >90 to <15 mL/min/1.73 m2. Kidney dysfunction was defined by an eGFR < 60 mL/min/1.73 m2. Patients with T2D showed a higher prevalence of CVD (37.9% versus 23.6%; P < 0.001) and kidney dysfunction (25% versus 13.2%; P < 0.001) than in the general population. An association with CVD was found with eGFR stages from 30 to 90 mL/min/1.73 m2 in T2D and from <15 to 90 mL/min/1.73 m2 in general population, in whom the association of eGFR with coronary heart disease was in an inverse relationship (P < 0.01 for trend). Survival, in diabetes, was lower (P = 0.037) but not associated with kidney dysfunction. Conclusions. In a high risk population, patients admitted to hospital, the relationship of kidney function with CVD is different between T2D and the general population. Competing mortality and the presence of other major risk factors in diabetes may be responsible for this difference.

Does comprehensive geriatric assessment improve the estimate of surgical risk in elderly patients? An Italian multicenter observational study.

BACKGROUND: The evaluation of surgical risk is crucial in elderly patients. At present, there is little evidence of the usefulness of comprehensive geriatric assessment (CGA) as a part of the overall assessment of surgical elderly patients. METHODS: We verified whether CGA associated with established surgical risk assessment tools is able to improve the prediction of postoperative morbidity and mortality in 377 elderly patients undergoing elective surgery. RESULTS: Overall mortality and morbidity were 2.4% and 19.9%, respectively. Multivariate analysis showed that impaired cognitive function (odds ratio [OR], 1.33; 95% confidence interval [CI], 1.15 to 4.22; P < .02) and higher Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (OR, 1.11; 95% CI, 1.00 to 1.23; P < .04) are predictive of mortality. Higher comorbidity is predictive of morbidity (OR, 2.12; 95% CI, 1.06 to 4.22; P < .03) and higher American Society of Anesthesiologists (OR, 2.18; 95% CI, 1.31 to 3.63; P < .001) and National Confidential Enquiry into Patient Outcome of Death score (OR, 2.03; 95% CI, 1.03 to 4.00; P < .04). CONCLUSIONS: In elective surgical elderly patients, the morbidity and mortality are low. The use of CGA improves the identification of elderly patients at higher risk of adverse events, independent of the surgical prognostic indices.

Fracture prevention service to bridge the osteoporosis care gap.

BACKGROUND: A care gap exists between the health care needs of older persons with fragility fractures and the therapeutic answers they receive. The Fracture Prevention Service (FPS), a tailored in-hospital model of care, may effectively bridge the osteoporosis care gap for hip-fractured older persons. The purpose of this study was to evaluate the efficacy of the FPS in targeting persons at high risk of future fracture and to improve their adherence to treatment. METHODS: This was a prospective observational study conducted in a teaching hospital with traumatology and geriatric units, and had a pre-intervention and post-intervention phase. The records of 172 participants were evaluated in the pre-intervention phase, while data from 210 participants were gathered in the post-intervention phase. All participants underwent telephone follow-up at 12 months after hospital discharge. The participants were patients aged ≥65 years admitted to the orthopedic acute ward who underwent surgical repair of a proximal femoral fracture. A multidisciplinary integrated model of care was established. Dedicated pathways were implemented in clinical practice to optimize the identification of high-risk persons, improve their evaluation through bone mineral density testing and blood examinations, and initiate an appropriate treatment for secondary prevention of falls and fragility fractures. RESULTS: Compared with the pre-intervention phase, more hip-fractured persons received bone mineral density testing (47.62% versus 14.53%, P<0.0001), specific pharmacological treatments (48.51% versus 17.16%, P<0.0001), and an appointment for evaluation at a fall and fracture clinic (52.48% versus 2.37%, P<0.0001) in the post-intervention phase. Independent of some confounders, implementation of the FPS was positively associated with recommendations for secondary fracture prevention at discharge (P<0.0001) and with 1-year adherence to pharmacological treatment (P<0.0001). CONCLUSION: The FPS is an effective multidisciplinary integrated model of care to optimize identification of older persons at highest risk for fragility fracture, to improve their clinical management, and to increase adherence to prescriptions.

Subsyndromal delirium and its determinants in elderly patients hospitalized for acute medical illness.

BACKGROUND: In older individuals, acute medical illnesses and admission to hospital are often associated with a deterioration of cognitive status, also in the absence of dementia and full-blown delirium. We evaluated the prevalence of subsyndromal delirium (SSD) and its correlates in a sample of elderly medical inpatients. METHODS: From 763 consecutive inpatients, 325 participants with known dementia or delirium were excluded, whereas 438 (mean age: 80.6 years; female participants: 60.1%) were enrolled. SSD was diagnosed within 48 hour from admission, when at least two DSM-IV delirium criteria including disorientation, attention or memory deficit, altered level of consciousness, or perceptual disturbances were present. Cognitive performance was evaluated by Mini Mental Status Examination (MMSE). General, clinical, and laboratory parameters were also registered. RESULTS: One hundred and sixty-six patients (37%) had SSD. Compared with controls, SSD patients were older individuals, had less formal education, higher comorbidity, lower hemoglobin/lymphocytes counts, and higher creatinine levels. A trend toward higher prevalence of previous stroke and widowhood was observed. A MMSE score of less than 24/30 identified SSD with 88% sensitivity and 78% specificity. In SSD patients, MMSE independently correlated with years of education, high-sensitivity C reactive protein levels, and O2 arterial saturation (model adjusted r (2) = 0.30, p = .001); conversely, only years of education were associated with MMSE in controls (adjusted r (2) = 0.06, p = .01). CONCLUSIONS: Our data suggest that SSD is common in hospitalized older medical inpatients, and low MMSE score might be useful for identification of participants at risk of SSD. Current inflammatory response and reduced O2 arterial saturation were the only independent determinants of cognitive performance in SSD patients.

The prevention of adverse drug reactions in older subjects.

Adverse drug reactions (ADRs) are a public health problem in older subjects, being responsible for a significant morbidity, disability and mortality. Older subjects are more susceptible to develop ADRs mainly due to polypharmacy, multimorbidity and inappropriate prescribing. The prevention of these drug related negative events represents an important aim for physicians treating older patients. Several strategies could potentially be employed, including state of the art education of medical students and physicians concerning principles of geriatric medicine and appropriate prescription in older subjects, reduction of inappropriate drug use by means of computerized decision support systems, pharmacist involvement and comprehensive geriatric assessment, and finally the identification of at risk older patients. However, there is currently a lack of scientific evidence demonstrating that these strategies can achieve a reduction in ADRs and therefore future intervention studies should be performed to evaluate the best intervention to decrease the burden of drug related problems in the older population.

A multi-dimensional questionnaire quantifying quality of life in elderly osteoporotic women: the Italian triple-Q osteoporosis study.

BACKGROUND AND AIMS: In advanced age, the influence of vertebral fractures on quality of life extends well beyond the usual sequelae of osteoporosis. In order to intercept older subjects' distress associated with the clinical, functional, social and psychological consequences of the disease, we developed and validated a multidimensional instrument (the triple-Q questionnaire) tailored to older women with osteoporotic fractures. We also examined specific aspects of the questionnaire correlated with bone mineral density. METHODS: 100 osteoporotic women with vertebral fractures and 100 controls aged >65 years, underwent a thorough examination, which also included X-ray of the thoraco-lumbar spine, hip densitometry, the triple-Q questionnaire, and five referral instruments evaluating function, cognition, perception of general health, mood and pain. RESULTS: The questionnaire was repeatable and able to discriminate between older women with and without vertebral fractures. There was a strong association between referral instrument scores and the corresponding single domain score of the questionnaire. Femoral BMD was also associated with scores indicating fear of falling, fear of fracture, and pain. CONCLUSIONS: The questionnaire intercepted the influence of osteoporosis on the quality of life of elderly women with vertebral fractures. Subjects who suffered from severe pain and were more fearful of falling were most likely to be severely osteoporotic.