Geriatric syndromes and functions in older adults with COVID-19 hospitalized in sub-acute care: a multicenter study.

OBJECTIVE: Alternatives to conventional acute hospitalizations have been particularly useful during the COVID-19 pandemic. However, little is known on the management and outcomes of COVID-19 in older patient admitted to non-acute settings. The main aim of this study was to determine the effect of geriatrics syndromes on functional outcomes in older COVID-19 patients cared in sub-acute units. METHODS: Prospective multicenter observational cohort study of patients aged 65 years and older with COVID-19, admitted to sub-acute units in Italy and Spain. Multivariable logistic regression models were used to test the association between geriatric syndromes and other clinical variables, and the functional status at discharge, defined by a Barthel Index > = 80. RESULTS: A total of 158 patients were included in the study with a median age of 82 [Interquartile Range 81, 83]; of these 102 (65%) patients had a Barthel Index ≥ 80 at discharge. In the main multivariable logistic regression model a higher severity of frailty-measured with the Clinical Frailty Scale-(OR 0.30; CI 0.18-0.47), and the presence of delirium (OR 0.04; CI 0.00-0.35) at admission were associated with lower odds of a higher functional status at discharge. Other variables associated with lower functional status were female gender (OR 0.36; CI 0.13-0.96), and a higher number of comorbidities (OR 0.48; CI 0.26-0.82). CONCLUSION: The study reports a relatively high prevalence of functional recovery for older COVID-19 patients admitted to sub-acute units. Additionally, it underlines the importance of targeting geriatrics syndromes, in particular frailty and delirium, for their possible effects on functional recovery.

A retrospective multicentre cohort study of the performances on attention tests in outpatients with cognitive dysfunctions without delirium.

OBJECTIVE: Attention is the cardinal feature of delirium, but attentional domains may also be affected by dementia and its severity. It is, therefore, of interest to study the correlation between the severity of cognitive impairment in non-delirious patients and different measurements of attentional performance, to identify attention subdomains less affected by severity of cognitive impairment. METHODS: Neuropsychological data from non-delirious outpatients (age ≥ 65 years), presenting at two memory clinics were analysed retrospectively. Scores for selective, divided, and sustained attention were correlated with cognitive impairment as defined by the score of the Mini-Mental State Examination. RESULTS: A total of 1658 outpatients were included. The mean age was 77.15 (± 8.17) years, with a mean MMSE score of 22.67 (± 4.91). Compared to the type of attention, the tests that are less influenced by the severity of cognitive impairment are those of selective attention, in particular the Digit Span Forward (DSF). CONCLUSIONS: This is the first study to correlate deficits in attention subdomains with the degree of cognitive impairment in non-delirious patients. The results suggest that measurements of selective attention (i.e. DSF) might be better suited to discriminate delirium from dementia. Indeed, a lower score on these tests might be indicative of an acute change and worsening of the baseline inattention and a longitudinal monitoring of these changes might be used to determine the delirium resolution.

Delirium symptoms duration and mortality in SARS-COV2 elderly: results of a multicenter retrospective cohort study.

BACKGROUND: Since the occurrence of the SARS-COV2 pandemic, there has been an increasing interest in investigating the epidemiology of delirium. Delirium is frequent in SARS-COV2 patients and it is associated with increased mortality; however, no information is available on the association between delirium duration in SARS-COV2 patients and related outcomes. AIMS: The aim of this study is to investigate the association between the duration of delirium symptoms and in-hospital mortality in older patients with SARS-COV2 infection. METHODS: Retrospective cohort study of patients 65 years of age and older with SARS-CoV 2 infection admitted to two acute geriatric wards and one rehabilitation ward. Delirium symptoms duration was assessed retrospectively with a chart-based validated method. In-hospital mortality was ascertained via medical records. RESULTS: A total of 241 patients were included. The prevalence of delirium on admission was 16%. The median number of days with delirium symptoms was 4 (IQR 2-6.5) vs. 0 (IQR 0-2) in patients with and without delirium on admission. In the multivariable Cox regression model, each day with a delirium symptom in a patient with the same length of stay was associated with a 10% increase in in-hospital mortality (Hazard ratio 1.1, 95% Confidence interval 1.01-1.2; p = 0.03). Other variables associated with increased risk of in-hospital death were age, comorbidity, CPAP, CRP levels and total number of drugs on admission. CONCLUSIONS: The study supports the necessity to establish protocols for the monitoring and management of delirium during emergency conditions to allow an appropriate care for older patients.

Preliminary investigation of predictors of distress in informal caregivers of patients with delirium superimposed on dementia.

OBJECTIVE: Delirium superimposed on dementia (DSD) is common and associated with adverse outcomes. Current evidence indicates that some patients with dementia may recall delirium with distress for them and their caregivers. The aim of this study is to identify predictors of distress in informal caregivers of older patient with DSD. METHODS: A total of 33 caregivers of 33 patients with DSD were interviewed 3 days after the resolution of delirium (T0) and at 1-month follow-up (T1) to describe their level of distress related to the delirium episode. A linear regression was used to identify predictors of caregivers' distress at T0 and T1 defined a priori: age, sex, level of education, employment status, delirium subtypes, delirium severity, type and severity of dementia, and the time spent with the patient during the delirium episode. RESULTS: Caregivers were mostly female (81%), 59 (± 13.0) years old on average. The predictors of distress at T0 were the patient's severity of both dementia and delirium. Moderate dementia was associated with lower distress, whereas higher delirium severity was associated with greater distress. At 1-month follow-up, the predictors of distress were the age of caregiver and time spent in care; the distress level was higher when caregivers were older, and they spent less time with their loved one. CONCLUSIONS: These preliminary findings underline the importance of providing continuous training and support for the caregivers, especially in coping strategies, in order to improve the care of DSD patients and prevent the caregivers' distress in long time period.

The impact of COVID-19 on health status of home-dwelling elderly patients with dementia in East Lombardy, Italy: results from COVIDEM network.

BACKGROUND: COVID-19 outbreak has led to severe health burden in the elderly. Age, morbidity and dementia have been associated with adverse outcome. AIMS: To evaluate the impact of COVID-19 on health status in home-dwelling patients. METHODS: 848 home-dwelling outpatients with dementia contacted from April 27 to 30 and evaluated by a semi-structured interview to evaluate possible health complication due to COVID-19 from February 21 to April 30. Age, sex, education, clinical characteristics (including diagnosis of dementia) and flu vaccination history were obtained from previous medical records. Items regarding change in health status and outcome since the onset of the outbreak were collected. COVID-19 was diagnosed in patients who developed symptoms according to WHO criteria or tested positive at nasal/throat swab if hospitalized. Unplanned hospitalization, institutionalization and mortality were recorded. RESULTS: Patients were 79.7 years old (SD 7.1) and 63.1% were females. Ninety-five (11.2%) patients developed COVID-19-like symptoms. Non COVID-19 and COVID-19 patients differed for frequency of diabetes (18.5% vs. 37.9%, p < 0.001), COPD (7.3% vs. 18.9%, p < 0.001), and previous flu vaccination (56.7% vs. 37.9%, p < 0.001). Diabetes and COPD were positively associated with COVID-19, whereas higher dementia severity and flu vaccination showed an inverse association. Among COVID-19 patients, 42 (44.2%) were hospitalized while 32 (33.7%) died. Non COVID-19 patients' hospitalization and mortality rate were 1.9% and 1.2%, respectively. COVID-19 and COPD were significantly associated with the rate of mortality. DISCUSSION/CONCLUSIONS: A high proportion of adverse outcome related to COVID-19 was observed in home-dwelling elderly patients with dementia. Active monitoring though telehealth programs would be useful particularly for those at highest risk of developing COVID-19 and its adverse outcomes.

The last week of life of nursing home residents with advanced dementia: a retrospective study.

BACKGROUND: Barriers to palliative care still exist in long-term care settings for older people, which can mean that people with advanced dementia may not receive of adequate palliative care in the last days of their life; instead, they may be exposed to aggressive and/or inappropriate treatments. The aim of this multicentre study was to assess the clinical interventions and care at end of life in a cohort of nursing home (NH) residents with advanced dementia in a large Italian region. METHODS: This retrospective study included a convenience sample of 29 NHs in the Lombardy Region. Data were collected from the clinical records of 482 residents with advanced dementia, who had resided in the NH for at least 6 months before death, mainly focusing on the 7 days before death. RESULTS: Most residents (97.1%) died in the NH. In the 7 days before death, 20% were fed and hydrated by mouth, and 13.4% were tube fed. A median of five, often inappropriate, drugs were prescribed. Fifty-seven percent of residents had an acknowledgement of worsening condition recorded in their clinical records, a median of 4 days before death. CONCLUSIONS: Full implementation of palliative care was not achieved in our study, possibly due to insufficient acknowledgement of the appropriateness of some drugs and interventions, and health professionals' lack of implementation of palliative interventions. Future studies should focus on how to improve care for NH residents.

Why older people stop to drive? A cohort study of older patients admitted to a rehabilitation setting.

The aim of this study is to describe the predictive factors of driving cessation at 6-month follow-up in older patients discharged from a rehabilitation setting and evaluated by an occupational therapist in a multidisciplinary team. Of 95 patients, at 6-month 27.4% ceased to drive. The reasons for driving cessation were a patients' voluntary choice (42.3%) or a choice of their family (23.1%), and only in 34.6% of the patients the license was revoked by a medical commission. In a multivariate analysis greater functional impairment-measured with the Timed Up and Go test-(OR 12.60, CI 2.74-57.89; p < 0.01) was the only predictor of driving cessation. This study shows that the ability to walk safely and independently is a significant predictor of driving cessation. The simple assessment of this factor using the TUG might be an easy screening tool to prompt a second level evaluation to accurately identify unsafe driving.

The association between patient participation and functional gain following inpatient rehabilitation.

OBJECTIVES: To evaluate patients' participation during physical therapy sessions as assessed with the Pittsburgh rehabilitation participation scale (PRPS) as a possible predictor of functional gain after rehabilitation training. METHODS: All patients aged 65 years or older consecutively admitted to a Department of Rehabilitation and Aged Care (DRAC) were evaluated on admission regarding their health, nutritional, functional and cognitive status. Functional status was assessed with the functional independence measure (FIM) on admission and at discharge. Participation during rehabilitation sessions was measured with the PRPS. Functional gain was evaluated using the Montebello rehabilitation factor score (MRFS efficacy), and patients stratified in two groups according to their level of functional gain and their sociodemographic, clinical and functional characteristics were compared. Predictors of poor functional gain were evaluated using a multivariable logistic regression model adjusted for confounding factors. RESULT: A total of 556 subjects were included in this study. Patients with poor functional gain at discharge demonstrated lower participation during physical therapy sessions were significantly older, more cognitively and functionally impaired on admission, more depressed, more comorbid, and more frequently admitted for cardiac disease or immobility syndrome than their counterparts. There was a significant linear association between PRPS scores and MRFS efficacy. In a multivariable logistic regression model, participation was independently associated with functional gain at discharge (odds ratio 1.51, 95 % confidence interval 1.19-1.91). CONCLUSION: This study showed that participation during physical therapy affects the extent of functional gain at discharge in a large population of older patients with multiple diseases receiving in-hospital rehabilitation.

Validation of the 4AT, a new instrument for rapid delirium screening: a study in 234 hospitalised older people.

OBJECTIVE: to evaluate the performance of the 4 'A's Test (4AT) in screening for delirium in older patients. The 4AT is a new test for rapid screening of delirium in routine clinical practice. DESIGN: : prospective study of consecutively admitted elderly patients with independent 4AT and reference standard assessments. SETTING: : an acute geriatrics ward and a department of rehabilitation. PARTICIPANTS: two hundred and thirty-six patients (aged ≥70 years) consecutively admitted over a period of 4 months. MEASUREMENTS: in each centre, the 4AT was administered by a geriatrician to eligible patients within 24 h of admission. Reference standard delirium diagnosis (DSM-IV-TR criteria) was obtained within 30 min by a different geriatrician who was blind to the 4AT score. The presence of dementia was assessed using the Alzheimer's Questionnaire and the informant section of the Clinical Dementia Rating scale. The main outcome measure was the accuracy of the 4AT in diagnosing delirium. RESULTS: patients were 83.9 ± 6.1 years old, and the majority were women (64%). Delirium was detected in 12.3% (n = 29), dementia in 31.2% (n = 74) and a combination of both in 7.2% (n = 17). The 4AT had a sensitivity of 89.7% and specificity 84.1% for delirium. The areas under the receiver operating characteristic curves for delirium diagnosis were 0.93 in the whole population, 0.92 in patients without dementia and 0.89 in patients with dementia. CONCLUSIONS: the 4AT is a sensitive and specific method of screening for delirium in hospitalised older people. Its brevity and simplicity support its use in routine clinical practice.

The effect of poststroke delirium on short-term outcomes of elderly patients undergoing rehabilitation.

OBJECTIVES: Delirium is a common poststroke complication, but its prevalence and effect in rehabilitation settings is unknown. We retrospectively assessed the prevalence of delirium in elderly patients undergoing poststroke rehabilitation and its association with short-term outcomes. METHODS: All patients (aged ≥65 years) admitted to the Department of Rehabilitation between November 2007 and October 2011 after a recent stroke were screened for delirium. Delirium was diagnosed using the confusion assessment method. Multiple logistic regressions were used to evaluate the association between delirium, institutionalization, and inhospital death, while multiple linear regressions were used for the association between delirium and functional recovery, defined in 3 different ways which include (1) measuring the relative functional gain of the Barthel index (BI-RFG); (2) the change in Barthel index (BI) walking subscore from admission to discharge; and (3) the change in Tinetti score from admission to discharge. RESULTS: In all, 58 (33%) patients of the total 176 patients were consecutively admitted to our department with delirium. After adjustment for potential confounders, poststroke delirium (PSD) was an independent predictor of institutionalization (odds ratio [OR] = 7.23; 95% confidence interval [CI] = 4.79 to 10.91; P ≤ .0003) and inhospital death (OR = 4.26; 95% CI = 1.15 to 15.81; P = .03); PSD was not a predictor of functional recovery at discharge, neither using the BI-RFG (P = .96) nor using the change from admission to discharge of both the BI walking subscore (P = .57) and the Tinetti score (P = .61) as outcome measures. CONCLUSIONS: In elderly patients undergoing poststroke rehabilitation, delirium is an independent predictor of institutionalization and inhospital death, but it does not affect functional recovery.

Chronic emphysematous osteomyelitis.

Emphysematous osteomyelitis (EO) is a rare and dangerous infection characterized by the presence of intraosseous gas. In this case report, a 65-year-old man with primary central nervous system lymphoma had recurrent infections and pain in his shoulders. Urine and blood cultures revealed Klebsiella pneumoniae. CT showed the formation of gas in the right humerus and left clavicle penetrating the surrounding tissues, which led to the diagnosis of EO. After several long-term antibiotic treatments, the patient underwent surgery on the right proximal humerus. Biopsy cultures revealed K. pneumoniae.

Exploratory pharmacovigilance with machine learning in big patient data: A focused scoping review.

BACKGROUND: Machine learning can operationalize the rich and complex data in electronic patient records for exploratory pharmacovigilance endeavours. OBJECTIVE: The objective of this review is to identify applications of machine learning and big patient data in exploratory pharmacovigilance. METHODS: We searched PubMed and Embase and included original articles with an exploratory pharmacovigilance purpose, focusing on medicinal interventions and reporting the use of machine learning in electronic patient records with ≥1000 patients collected after market entry. FINDINGS: Of 2557 studies screened, seven were included. Those covered six countries and were published between 2015 and 2021. The most prominent machine learning methods were random forests, logistic regressions, and support vector machines. Two studies used artificial neural networks or naive Bayes classifiers. One study used formal concept analysis for association mining, and another used temporal difference learning. Five studies compared several methods against each other. The numbers of patients in most data sets were in the order of thousands; two studies used what can more reasonably be considered big data with >1 000 000 patients records. CONCLUSION: Despite years of great aspirations for combining machine learning and clinical data for exploratory pharmacovigilance, only few studies still seem to deliver somewhat on these expectations.

Dysphagia in older patients admitted to a rehabilitation setting after an acute hospitalization: the role of delirium.

INTRODUCTION: Dysphagia is a swallowing disorder that affects 8% of the world population. However, data are lacking on its prevalence in a heterogeneous group of older patients. The aim of this study is to evaluate the prevalence of dysphagia at admission and at discharge, and its related factors, in particular delirium, in older patients admitted to a rehabilitation setting. METHODS: Retrospective cohort study of patients 65 years and older admitted to a rehabilitation ward after an acute hospitalization. The presence of dysphagia at admission was screened with the 3OZ Test and confirmed by a speech-therapist. The association between clinical factors and dysphagia was investigated with a multivariate logistic regression analysis. RESULTS: We included 1040 patients, (65% females, mean age 81.9 ± 7.2 years). The prevalence of dysphagia at admission was 14.8% and 12.8% at discharge, while the prevalence of delirium among patients with dysphagia was of 31.2% vs 6.4% among patients without dysphagia. The severity of dysphagia was moderate. In the multivariate logistic regression, delirium was associated with dysphagia at admission (OR 2.06; Confidence Interval, CI 1.08-3.23) along with a pre-hospital impairment in the Instrumental-Activities-of-Daily-Living (OR-1.26; CI - 1.1; - 1.10), a change in Barthel Index from pre-hospital to hospital admission (OR-1.02; CI - 1.01 to 1.04), comorbidity (OR 1.12; CI 0.94;1.29) and the number of antibiotics (OR-1.63; CI - 1.01;2.62). CONCLUSION: Delirium was the main factor associated with dysphagia at rehabilitation admission. The study underlines the importance of screening dysphagia in delirious patients and warrants future studies to determine the changes in dysphagia prevalence according to delirium resolution.

Healthcare Resource Consumption and Related Costs in Patients on Antiretroviral Therapies: Findings from Real-World Data in Italy.

This real-world analysis conducted on administrative databases of a sample of Italian healthcare entities was aimed at describing the role of therapeutic pathways and drug utilization in terms of adherence, persistence, and therapy discontinuation in HIV-infected patients under antiretroviral therapies (ART) and Tenofovir Alafenamide (TAF)-based regimens on healthcare resource consumption and related direct healthcare costs. Between 2015 and 2019, adults (≥18 years) prescribed with TAF-based therapies were identified and characterized in the year prior to the first prescription (index-date) for TAF-based therapies and followed-up until the end of data availability. Overall, 2658 ART-treated patients were included, 1198 of which were under a TAF-based regimen. TAF-based therapies were associated with elevated percentages of adherence (83.3% patients with proportion of days covered, PDC > 95% and 90.6% with PDC > 85%) and persistence (78.5%). The discontinuation rate was low in TAF-treated patients, ranging from 3.3% in TAF-switchers to 5% in naïve. Persistent patients had lower overall mean annual healthcare expenditures (EUR 11,106 in persistent vs. EUR 12,380 in non-persistent, p = 0.005), and this trend was statistically significant also for costs related to HIV hospitalizations. These findings suggest that a better therapeutic management of HIV infection might result in positive clinical and economic outcomes.

Profile, Healthcare Resource Consumption and Related Costs in ANCA-Associated Vasculitis Patients: A Real-World Analysis in Italy.

INTRODUCTION: Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAV) are rare autoimmune diseases triggering inflammation of small vessels. This real-world analysis was focused on the most common AAV forms, granulomatosis with polyangiitis (GPA) and microscopic polyangiitis (MPA), to describe patients' demographic and clinical characteristics, therapeutic management, disease progression, and the related economic burden. METHODS: A retrospective analysis was conducted on administrative databases of a representative sample of Italian healthcare entities, covering approximately 12 million residents. Between January 2010 and December 2020, adult GPA patients were identified by payment waiver code or hospitalization discharge diagnosis, and MPA patients by payment waiver code with or without hospitalization discharge diagnosis. Clinical outcomes were evaluated through AAV-related hospitalizations, renal failure onset, and mortality. Economic analysis included healthcare resource utilization deriving from drugs, hospitalizations, and outpatient specialist services. The related mean direct costs year/patient were also calculated in patients stratified by presence/absence of glucocorticoid therapy and type of inclusion criterion (hospitalization/payment waiver code). RESULTS: Overall, 859 AAV patients were divided into GPA (n = 713; 83%) and MPA (n = 146; 17%) cohorts. Outcome indicators highlighted a clinically worse phenotype associated with GPA compared to MPA. Cost analysis during follow-up showed tendentially increased expenditures in glucocorticoid-treated patients versus untreated (overall AAV: €8728 vs. €7911; GPA: €9292 vs. €9143; MPA: €5967 vs. €2390), mainly driven by drugs (AAV: €2404 vs. €874; GPA: €2510 vs. €878; MPA: €1881 vs. €854) and hospitalizations. CONCLUSION: Among AAV forms, GPA resulted in a worse clinical picture, higher mortality, and increased costs. This is the first real-world pharmaco-economic analysis on AAV patients stratified by glucocorticoid use on disease management expenditures. In both GPA and MPA patients, glucocorticoid treatment resulted in higher healthcare costs, mostly attributable to medications, and then hospitalizations, confirming the clinical complexity and economic burden for management of patients with autoimmune diseases under chronic immunosuppression.

Language-agnostic pharmacovigilant text mining to elicit side effects from clinical notes and hospital medication records.

We sought to craft a drug safety signalling pipeline associating latent information in clinical free text with exposures to single drugs and drug pairs. Data arose from 12 secondary and tertiary public hospitals in two Danish regions, comprising approximately half the Danish population. Notes were operationalised with a fastText embedding, based on which we trained 10 270 neural-network models (one for each distinct single-drug/drug-pair exposure) predicting the risk of exposure given an embedding vector. We included 2 905 251 admissions between May 2008 and June 2016, with 13 740 564 distinct drug prescriptions; the median number of prescriptions was 5 (IQR: 3-9) and in 1 184 340 (41%) admissions patients used ≥5 drugs concomitantly. A total of 10 788 259 clinical notes were included, with 179 441 739 tokens retained after pruning. Of 345 single-drug signals reviewed, 28 (8.1%) represented possibly undescribed relationships; 186 (54%) signals were clinically meaningful. Sixteen (14%) of the 115 drug-pair signals were possible interactions, and two (1.7%) were known. In conclusion, we built a language-agnostic pipeline for mining associations between free-text information and medication exposure without manual curation, predicting not the likely outcome of a range of exposures but also the likely exposures for outcomes of interest. Our approach may help overcome limitations of text mining methods relying on curated data in English and can help leverage non-English free text for pharmacovigilance.

Analysis of Patients with Focal Epilepsy and Drug-Resistant Epilepsy in Italy: Evaluation of Their Characteristics, Therapeutic Pathway and the Consumption of Healthcare Resources.

Purpose: A retrospective analysis was conducted to estimate the number of patients with focal epilepsy and drug-resistant epilepsy (DRE) and their characteristics, the therapeutic patterns, the consumption of health resources in a real-world Italian setting. Patients and Methods: A retrospective study was carried out on the administrative databases of a sample of Italian Health Departments, covering approximately 8.7 million health-assisted individuals. All adult patients with at least one hospitalization for focal epilepsy and an electroencephalogram (between 01/2010 and 12/2019), and at least one prescription of antiseizure medication (ASM) (between 01/2011 and 12/2018) were included in the study. Patients with at least two treatment failures and treated with a subsequent ASM were considered DRE. Results: Overall, 1897 patients with focal epilepsy (mean age 56 years, 47% male) were identified, of which 485 (25.6%) with DRE (mean age 53 years, 43% male). Among patients with focal epilepsy and DRE, respectively, 48% and 54% had essential hypertension, 23.4% and 26.6% had cardiovascular disease, and 46.3% and 62.1% had peptic ulcer/prescription of gastric secretion inhibitors. During follow-up, patients with focal epilepsy maintained first-line treatment for 53.9 months; among these, 52% passed to the second-line, and 485 (25.6% of the total) began third-line treatment. In patients with focal epilepsy, the mean cost was € 4448 (of which € 1410 were epilepsy-related), and in DRE patients total expenditures averages € 5825 (of which € 2165 were epilepsy-related). In both patients with focal epilepsy and DRE, hospitalizations represented the most impacting item of expenditure. Conclusion: The present analysis conducted in a setting of Italian clinical practice has shown that 25% of patients with focal epilepsy were resistant to antiepileptic treatments. Furthermore, these results showed that health-care costs for the management of epileptic patients were mainly accountable for the costs related to the disease-management and to hospitalizations.

Visual and Hearing Impairment Are Associated With Delirium in Hospitalized Patients: Results of a Multisite Prevalence Study.

OBJECTIVE: Sensory deficits are important risk factors for delirium but have been investigated in single-center studies and single clinical settings. This multicenter study aims to evaluate the association between hearing and visual impairment or bi-sensory impairment (visual and hearing impairment) and delirium. DESIGN: Cross-sectional study nested in the 2017 "Delirium Day" project. SETTING AND PARTICIPANTS: Patients 65 years and older admitted to acute hospital medical wards, emergency departments, rehabilitation wards, nursing homes, and hospices in Italy. METHODS: Delirium was assessed with the 4AT (a short tool for delirium assessment) and sensory deficits with a clinical evaluation. We assessed the association between delirium, hearing and visual impairment in multivariable logistic regression models, adjusting for: Model 1, we included predisposing factors for delirium (ie, dementia, weight loss and autonomy in the activities of daily living); Model 2, we added to Model 1 variables, which could be considered precipitating factors for delirium (ie, psychoactive drugs and urinary catheters). RESULTS: A total of 3038 patients were included; delirium prevalence was 25%. Patients with delirium had a higher prevalence of hearing impairment (30.5% vs 18%; P < .001), visual impairment (24.2% vs 15.7%; P < .01) and bi-sensory impairment (16.2% vs 7.5%) compared with those without delirium. In the multivariable logistic regression analysis, the presence of bi-sensory impairment was associated with delirium in Model 1 [odds ratio (OR) 1.5, confidence interval (CI) 1.2-2.1; P = .00] and in Model 2 (OR 1.4; CI 1.1-1.9; P = .02), whereas the presence of visual and hearing impairment alone was not associated with delirium either in Model 1 (OR 0.8; CI 0.6-1.2, P = .36; OR 1.1; CI 0.8-1.4; P = .42) or in Model 2 (OR 0.8, CI 0.6-1.2, P = .27; OR 1.1, CI 0.8-1.4, P = .63). CONCLUSIONS AND IMPLICATIONS: Our findings support the importance of routine screening and specific interventions by a multidisciplinary team to implement optimal management of sensory impairments and hence prevention and the management of the patients with delirium.

The 4-DSD: A New Tool to Assess Delirium Superimposed on Moderate to Severe Dementia.

OBJECTIVES: The purpose of this study was to create, standardize, and validate a new instrument, named 4-DSD, and determine its diagnostic accuracy in the diagnosis of delirium in subjects with moderate to severe dementia. DESIGN: Multicenter cross-sectional observational study. SETTING AND PARTICIPANTS: Older patients consecutively admitted to acute and rehabilitation hospital wards. MEASURES: The DSM-5 was used as the reference standard delirium assessment. The presence and severity of dementia was defined using the AD8 and the Global Deterioration Scale (GDS). The 4-DSD is a 4-item tool that ranges from 0 to 12. Item 1 measures alertness, item 2 altered function, item 3 attention, and item 4 acute change or fluctuation in mental status. RESULTS: A total of 134 patients were included in the study. Most of the patients were enrolled in acute hospital wards (60%), with 40% in rehabilitation settings. A minority of the patients were categorized with moderate dementia, with a GDS score of 5 (4%). Most of the patients were in the moderate-severe stage with a GDS score ≤6 (77%); 19% were classed as severe, with a GDS score of 7. A 4-DSD cutoff score ≥5 had a sensitivity of 80% and specificity of 80% with a positive predictive value (PPV) of 67% and a negative predictive value (NPV) of 89%. In the subgroup with moderate-severe dementia (n = 108), the sensitivity and the specificity were 79% and 82%, respectively, with a PPV and NPV of 62% and 92%. In the subgroup with severe dementia (n = 26) the sensitivity was 82% and the specificity 56% with a PPV of 78% and a NPV of 63%. CONCLUSIONS AND IMPLICATIONS: The availability of a specific tool to detect delirium in patients with moderate-severe dementia has important clinical and research implications, allowing all health care providers to improve their ability to identify it.

Delirium in Patients with SARS-CoV-2 Infection: A Multicenter Study.

OBJECTIVES: The aims of this study are to report the prevalence of delirium on admission to the unit in patients hospitalized with SARS-CoV-2 infection, to identify the factors associated with delirium, and to evaluate the association between delirium and in-hospital mortality. DESIGN: Multicenter observational cohort study. SETTINGS: Acute medical units in four Italian hospitals. PARTICIPANTS: A total of 516 patients (median age 78 years) admitted to the participating centers with SARS-CoV-2 infection from February 22 to May 17, 2020. MEASUREMENTS: Comprehensive medical assessment with detailed history, physical examinations, functional status, laboratory and imaging procedures. On admission, delirium was determined by the Diagnostic and Statistical Manual of Mental Disorders (5th edition) criteria, 4AT, m-Richmond Agitation Sedation Scale, or clinical impression depending on the site. The primary outcomes were delirium rates and in-hospital mortality. RESULTS: Overall, 73 (14.1%, 95% confidence interval (CI) = 11.0-17.3%) patients presented delirium on admission. Factors significantly associated with delirium were dementia (odds ratio, OR = 4.66, 95% CI = 2.03-10.69), the number of chronic diseases (OR = 1.20, 95% CI = 1.03; 1.40), and chest X-ray or CT opacity (OR = 3.29, 95% CI = 1.12-9.64 and 3.35, 95% CI = 1.07-10.47, for multiple or bilateral opacities and single opacity vs no opacity, respectively). There were 148 (33.4%) in-hospital deaths in the no-delirium group and 43 (58.9%) in the delirium group (P-value assessed using the Gray test <.001). As assessed by a multivariable Cox model, patients with delirium on admission showed an almost twofold increased hazard ratio for in-hospital mortality with respect to patients without delirium (hazard ratio = 1.88, 95% CI = 1.25-2.83). CONCLUSION: Delirium is prevalent and associated with in-hospital mortality among older patients hospitalized with SARS-CoV-2 infection.