Hyponatremia, Hypokalemia, and Fragility Fractures in Old Patients: More than an Association?

PURPOSE: Hyponatremia and hypokalemia are common among elderly and have been associated with osteoporosis, we evaluate the role of these electrolytes as risk for fragility fractures. METHODS: This study is divided in two parts: one retrospective and one prospective. We retrospectively collected data on urgently admitted patients for femoral fragility fractures (Fx) or for acute myocardial infarction (AMI), and patients admitted for elective hip/knee replacement surgery for osteoarthrosis (OA). Age, sex, serum sodium, potassium, creatinine, and comorbidities were recorded. We enrolled prospectively in-patients from our unit: age, sex, comorbidities, drugs, and fragility fractures were recorded. Blood electrolytes were measured. Cognitive function, nutrition, muscular strength, and balance were evaluated by standard tests. The mortality rate was recorded with a follow-up after hospital discharge. RESULTS: The retrospective study included 2166 subjects: 702 Fx and 1464 controls (907 AMI, 557 OA): the prevalence of hyponatremia was similar in Fx and AMI, whereas it was higher in Fx with respect to OA (p < 0.001) as well as hypokalemia (p < 0.001). Sodium decrease was associated with higher fracture risk. Among the 284 subjects included in the prospective study, 50 patients were hyponatremic, more likely malnourished, and presented a higher prevalence of fragility fractures (p = 0.008). They had a higher mortality after hospital discharge (HR = 1.80, p = 0.005), however, this association disappears after correction for confounding variables. CONCLUSIONS: We suggest that hyponatremia and hypokalemia have to be considered as a marker of poor health more than an independent fracture risk.

Prevalence, predictors and clinical implications of prolonged corrected QT in elderly patients with dementia and suspected syncope.

BACKGROUND: Long QT and use of QT-prolonging drugs are common among older patients receiving polytherapies, but real-world evidence on their impact in clinical practice is controversial. We investigated prevalence, variables associated and clinical implications of prolonged corrected QT (QTc) among patients from the Syncope and Dementia study. METHODS: Observational, prospective, multicenter study. Patients≥65 years with dementia and fall suspected for syncope in the previous three months were enrolled. Several clinical variables and the complete list of medications were recorded for each patient. A 12­lead ECG was obtained and corrected QT was calculated by the Bazett's formula. One-year followup for death and recurrent syncope was performed. RESULTS: Prolonged QTc was observed in 25% of the 432 enrolled patients (mean age 83.3), and was significantly associated with male gender (OR 2.09; 95% CI 1.34-3.26) and diuretics use (OR 1.85; 95% CI 1.18-2.90). At one-year 23.3% of patients died and 30.4% reported at least one recurrent event. Variables associated with one-year mortality were: age, male gender, atrial fibrillation (AF), use of calcium channel blockers and prolonged QTc (OR 1.80; 95% CI 1.01-3.20). Among patients with prolonged QTc a significant interaction for mortality was found with AF. Recurrent events were associated with the use of antiplatelets, cholinesterase. inhibitors and antipsychotics, but not with prolonged QTc. CONCLUSIONS: We documented a high prevalence of prolonged QTc, that was associated with male gender and diuretics but not with psychoactive medications. Patients with prolonged QTc had higher one-year mortality, that was four-fold increased in those with concomitant AF.

Length of Stay in the Emergency Department and Occurrence of Delirium in Older Medical Patients.

OBJECTIVES: To determine whether emergency department (ED) length of stay before ward admission is associated with incident delirium in older adults. DESIGN: Prospective cohort study. SETTING: Hospital. PARTICIPANTS: Individuals aged 75 and older without delirium at ED entry, coma, aphasia, stroke, language barrier, psychiatric disorder, or alcohol abuse (N = 330). MEASUREMENTS: On ED admission, individuals underwent standardized evaluation of comorbidity (Cumulative Illness Rating Scale), cognitive impairment (Short Portable Mental Status Questionnaire), functional independence (activities of daily living, instrumental activities of daily living), pain (Numeric Rating Scale), and acute clinical conditions (Acute Physiology and Chronic Health Evaluation II). During the first 3 days after ward admission, the presence of delirium (defined as ≥1 delirium episodes within 72 hours) was assessed daily using a rapid assessment for delirium (4AT scale). ED length of stay was calculated as the time (hours) between ED registration and when the person left the ED. RESULTS: ED length of stay longer than 10 hours (odds ratio (OR) = 2.23, 95% confidence interval (CI) = 1.13-4.41), moderate to severe cognitive impairment (OR = 5.47, 95% CI = 2.76-10.85), and older age (OR = 1.07, 95% CI = 1.01-1.13) were associated with delirium onset. CONCLUSION: ED length of stay longer than 10 hours was associated with greater risk of delirium in hospitalized older adults, after adjusting for age and cognitive impairment.