Clinical Presentation of COVID19 in Dementia Patients.

OBJECTIVE: No studies analyzing the role of dementia as a risk factor for mortality in patients affected by COVID-19. We assessed the prevalence, clinical presentation and outcomes of dementia among subjects hospitalized for COVID19 infection. DESIGN: Retrospective study. SETTING: COVID wards in Acute Hospital in Brescia province, Northern Italy. PARTICIPANTS: We used data from 627 subjects admitted to Acute Medical wards with COVID 19 pneumonia. MEASUREMENTS: Clinical records of each patients admitted to the hospital with a diagnosis of COVID19 infection were retrospectively analyzed. Diagnosis of dementia, modalities of onset of the COVID-19 infection, symptoms of presentation at the hospital and outcomes were recorded. RESULTS: Dementia was diagnosed in 82 patients (13.1%). The mortality rate was 62.2% (51/82) among patients affected by dementia compared to 26.2% (143/545) in subjects without dementia (p<0.001, Chi-Squared test). In a logistic regression model age, and the diagnosis of dementia resulted independently associated with a higher mortality, and patients diagnosed with dementia presented an OR of 1.84 (95% CI: 1.09-3.13, p<0.05). Among patients diagnosed with dementia the most frequent symptoms of onset were delirium, especially in the hypoactive form, and worsening of the functional status. CONCLUSION: The diagnosis of dementia, especially in the most advanced stages, represents an important risk factor for mortality in COVID-19 patients. The clinical presentation of COVID-19 in subjects with dementia is atypical, reducing early recognition of symptoms and hospitalization.

Good nutritional oral intake is associated with equal survival in demented and nondemented very old patients.

OBJECTIVE: To evaluate the association of oral food intake with survival in very old demented nursing home patients. DESIGN: A prospective cohort study. SETTING: A nursing home in northern Italy. MEASUREMENTS: Anthropometric and laboratory nutritional indicators and nutrient intake were assessed in 33 demented (age 85.7 +/- 5.7 years) and 25 nondemented (age 84.9 +/- 5.7 years) patients. Mortality data were collected over a 28-month follow-up period. Association of survival with dementia was estimated by Kaplan-Meyer analysis and multivariate Cox proportional hazard models. RESULTS: Nutrient intake and nutritional status were good compared with data in the literature and were similar in demented and nondemented patients, except for smaller triceps skinfold thickness in the demented. The cumulative annual death rate was 0.23 deaths per subject per year, similar in the demented (0.23) and the nondemented (0.22). Unadjusted survival by Kaplan-Meyer analysis was similar in the two groups, and correction for-age, gender, cognition, triceps skinfold thickness, and number of drugs in a Cox model did not alter the relationship. CONCLUSIONS: Dementia developing in very old age is not necessarily associated with malnutrition and decreased life expectancy.

A nutritional index predicting mortality in the nursing home.

OBJECTIVE: To define a sensitive and specific index, based on nutritional indicators, predicting mortality in nursing home patients. DESIGN: A prospective cohort study. SETTING: A nursing home. MEASUREMENTS: Anthropometric and laboratory nutritional indicators were assessed in 104 nursing home elderly residents (20 males, 84 females). Patients were aged 60 years and older and had relatively good somatic health and nutritional status. Mortality data were collected over an 18-month follow-up period. Discriminant analysis was used to compute an adimensional measure (index) that could predict mortality with the highest sensitivity and specificity. RESULTS: Mortality was 0.20/year. A nonlinear, "U-shaped" relationship of cholesterol levels with mortality was found. A prognostic index based on cholesterol, lymphocyte count, mid-arm circumference, hemoglobin, age, and gender was obtained. Higher values of this index were associated with progressively higher risks at 12 months and 18 months. Sensitivity and specificity calculated on 18-month mortality were 80% and 78.4%, respectively. CONCLUSIONS: This index, based on simple measures, can be a useful tool in the evaluation of health status of the elderly living in nursing homes.

The management of adverse clinical events in nursing homes: a 1-year survey study.

OBJECTIVE: In Italian nursing homes (NHs), care delivery at night and during holidays is not regulated by regional laws; some facilities employ staff physicians, others employ physicians engaged from year to year (temporary physicians), and others employ publicly funded National Health System (NHS) physicians. This study was designed to determine whether the use of different kinds of physicians leads to different outcomes with regard to the rate of hospitalization and appropriateness of the management of adverse clinical events. DESIGN: Prospective, nonrandomized-survey data collection. SETTING: Ten nonprofit nursing facilities in Italy. PARTICIPANTS: Three hundred and fifty-two NH residents, staff physicians, temporary physicians, and NHS physicians. MEASUREMENTS: Medical intervention during adverse clinical events occurring at night and during holidays. RESULTS: Three hundred and fifty-two residents experienced 551 adverse clinical events; 78 were hospitalized. The hospitalization rate of NHS physicians was about two times that of the temporary physicians and six times that of the staff physicians. Staff physicians' diagnoses and management were appropriate in the majority of cases; NHS diagnosis and management were doubtful or incorrect in about one-third of all cases. CONCLUSIONS: NH residents frequently experience adverse clinical events; physician characteristics influence the rate of hospitalization and the quality of medical interventions.

Food intake and mortality in the frail elderly.

BACKGROUND: Adequate qualitative and quantitative food intake is a major determinant of health. However, nutritional requirements in the elderly are unknown, and even more so in the frail elderly. The aim of the study was to evaluate the influence of energy and macro-nutrients on health in the frail nursing home elderly. METHODS: Food intake of 72 not severely diseased elderly patients was assessed with direct weighing method. Outcome measure was survival over 28-month follow-up period. Confounders of the association of food intake with survival were: age, gender, body-mass index, daily function, somatic health, anergy, and nutritional status. Crude association of food intake with survival was assessed with Kaplan-Meyer method, and adjusted association with multiple Cox regression models. RESULTS: Patients of the study had good average food intake. Mortality rate was relatively low (.20 per year). Low levels of energy, protein, lipid, and carbohydrate intake were negatively associated with survival even after adjustment for confounders. When compared to high intake, adjusted relative risks for mortality of low intake were 4.74, 3.75, 4.71, and 2.04, respectively. Medium levels of energy, protein, and lipid, but not carbohydrate, intake yielded intermediate mortality risk. CONCLUSIONS: Food intake is a strong predictor of survival even in moderately diseased elderly patients, suggesting possible low-cost interventions.

Brain magnetic resonance imaging in congenital hypothyroid infants at diagnosis.

The aim of our study was to investigate the central nervous system (CNS) morphology and myelination with magnetic resonance imaging (MRI) in congenital hypothyroid (CH) infants detected by neonatal screening before replacement therapy. We studied 11 CH infants, 9 girls and 2 boys, mean age 22 days, 3 with aplasia, 5 with ectopia, 2 with hypoplasia of the thyroid gland, 1 with unknown diagnosis. As normal controls 22 term newborns (38 to 41 weeks of gestational age) were studied. MRI studies were performed with a 1.5-T magnet, extremity coil, T1-weighted and heavily T2-sequences axial sections were obtained. No sedation was needed for the MRI studies. MRI brain examination was normal in all patients compared with controls. In particular, no differences in the myelination patterns of the brain were observed between normal subjects and patients with hypothyroidism. Our study shows no morphological brain abnormalities in CH infants detected by neonatal screening before replacement therapy. Perinatal hypothyroidism seems to have no effect on CNS structures.

Special care units for demented patients: a multicenter study.

The local government of Regione Lombardia, Italy, recently (1994) funded a clinical and research project specifically devoted to dementia (Piano Alzheimer). A central role in this project has been reserved for the special care units (SCUs) for demented patients with behavioral disturbances. In order to evaluate their effectiveness, eight SCUs took part in this study. A specifically designed care program, focusing on environment and staff, was implemented in each SCU. Cognitive, functional, and somatic health status, and use of psychotropic drugs and of physical restraints were assessed at baseline, and after 3 and 6 months in 55 consecutively admitted patients. The data show an overall reduction in behavioral disturbances and a decreased use of psychotropic drugs and physical restraints.

Proposal of a flexible structural-organizing model for the Intensive Care Units.

BACKGROUND: The aim of this study was to verify the capability of the Italian Group for the Evaluation of Intervention in Intensive Care Medicine (Gruppo Italiano Valutazione Interventi in Terapia Intensiva, GiViTI) Intensive Care Units (ICUs) in providing high level care (HLC) and to develop a flexible organiziational model, allowing for different levels of care in each ICU. METHODS: Once the number of active beds, personnel and technology of each ICU were determined, we computed whether the available bed number and all available resources could provide HLC according to international standards. For ICUs lacking staff or equipment for safe HLC in all declared beds, we calculated the best combination between HLC and observation/monitoring beds with less need for nurses and technology (low level of care, LLC) in order to optimise the utilization of each bed. We also investigated the work organisation of physicians and nurses in these units. RESULTS: There are 2 070 available beds in the 293 GiViTI ICUs. To provide HLC according to international criteria, the beds would decrease to 80.9%, because 144 ICUs do not have nurses or equipment to provide HLC in each bed. In order to maximize the suitable use of available resources, these ICUs would have to reduce the HLC bed number using the regained nurse workload for LLC. Because of this, the total number of HLC beds would further decrease to 65.9% of all declared beds. During Sundays and holidays, the bed/doctor and the bed/nurse ratios increase in most ICUs. CONCLUSION: To maximize the staff and equipment resources available, the bed numbers of a general ICU providing HLC must vary, even daily, according to the level of care provided. This level is not always high for all patients present. Applying this organizing model to each ICU, we could have enough flexibility to face the different demands for assistance if the ICU is built as a large open space to achieve the best clinical model and use of resources.

Continuous quality improvement in intensive care medicine. The GiViTI Margherita Project - Report 2005.

AIM: The assessment of the quality of intensive care medicine is mandatory in the modern healthcare system. In Italy, the GiViTI (Gruppo Italiano per la Valutazione degli Interventi in Terapia Intensiva) network is working in this field since 1991 and it now involves 295 out of the about 450 Italian intensive care units (ICU). In 2002 GiViTI launched a project for the continuous quality assessment and improvement that is now joined by 180 ICUs. Data collected in 2005 are analyzed and presented. METHODS: All admitted patients were entered in a validated software, which performs a multitude of validity checks during the data entry. Data were further reviewed by the co-ordinating center; patients admitted in months with more than 10% of incomplete or inconsistent records in each ICU were excluded from the analysis. Each year, a multivariate logistic regression model is fitted to identify predictors of hospital mortality. Starting from the SAPS 2 and the 2004 GiViTI model predictions of hospital mortality, two calibration tables and curves are presented. RESULTS: In 2005, 180 Italian ICUs collected data on 55 246 patients. After excluding those admitted in months with an unjustified lower recruitment rate or with less than 90% of complete and consistent data, we had 52 816 (95.6%) valid cases. Although the rough hospital mortality in 2005 was 1% higher than in 2004 (22.6% vs 21.5%), the adjusted mortality shows a statistically significant 4% reduction (obser-ved-to-expected ratio: 0.96; 95% CI: 0.94-0.97). CONCLUSIONS: Italian ICUs in 2005 performed better than in 2004, at a parity of patient severity.

Fear of falling in nursing home patients.

The study analyzes the characteristics of 54 nursing home patients (12 male, 42 female; mean age 81.9 +/- 7.9 years) with and without the complaint of the fear of falling, and the association of this fear with falling and functional status. Patients who had a fear of falling at baseline (n = 25) had a lower functional status (Barthel Index) score (69.8 +/- 22.3 vs. 79.3 +/- 15.4), lower scores for balance (8.4 +/- 4.4 vs. 10.6 +/- 3.7) and gait (Tinetti; 6.7 +/- 3.3 vs. 8.3 +/- 2.6) and were taking a higher number of psychotropic drugs (0.8 +/- 1.1 vs. 0.2 +/- 0.5) than those with no fear (n = 29). At 24 months' follow-up, 25 subjects were still available for evaluation. Fear of falling at baseline was predictive of a decline in activities of daily living, as measured by the Barthel Index, in a multiple regression model, after controlling for baseline cognitive function and change in cognitive function, age, gender, balance and gait, frequency of psychotropic drug usage, and number of chronic symptoms. The findings of this study suggests that, in mobile patients, the fear of falling can be a clinically important predictor of functional decline.

Assessment of functional ability with the bed rise difficulty scale in a group of elderly patients.

The aim of the study (part of the Progetto Longitudinale Gussago) was to evaluate the variables related to the difficulty in rising from a bed in 2 groups of elderly patients: nursing home residents, and patients admitted to a geriatric evaluation and management unit. Functional ability was tested through the bed rise difficulty scale (BRD). The version used in this study considered only those 7 items (out of 12) found to be of value. Only those patients who were able to rise from bed without help were selected in order to achieve the aim of the study (33 males, 113 females; mean age 79.6 +/- 7.3 years). Although the 146 patients assessed were considered as having a good functional level (Tinetti score 18.8 +/- 6.9, ADL Katz score 1.6 +/- 1.4), most of them had high scores on the BRD scale, indicating the ability of this scale to detect early, mild disability. The total score of the BRD scale was significantly related to the ADL Katz (r = 0.29, p = 0.000), Tinetti scale (r = -0.39, p = 0.000) and physical performance test (PTT; r = -0.47, p = 0.000). Similar results were obtained for the correlation between BRD time and ADL Katz (r = 0.033, p = 0.000), Tinetti scale (r = -0.30, p = 0.000) and PPT-(r = -0.46, p = 0.000). In a logistic regression analysis the items of the PPT scale considering upper extremity function and Tinetti balance score were significantly associated with the total bed rise time and score.