Prevalence and documented causes of hyponatraemia among geriatric patients attending a primary care clinic.

INTRODUCTION: Hyponatraemia is the commonest electrolyte abnormality and has major clinical implications. However, few studies of hyponatraemia in the primary care setting has been published to date. OBJECTIVES: To determine the prevalence, potential causes and management of hyponatraemia and to identify factors associated with severity of hyponatraemia among older persons in a primary care setting. METHODS: Electronic records were searched to identify all cases aged ≥60 years with a serum sodium <135mmol/l, attending outpatient clinic in 2014. Patients' medical records with the available blood test results of glucose, potassium, urea and creatinine were reviewed. RESULTS: Of the 21,544 elderly, 5873 patients (27.3%) had electrolyte profile tests. 403 (6.9%) had hyponatraemia in at least one blood test. Medical records were available for 253, mean age 72.9±7.3 years, 178 (70.4%) had mild hyponatraemia, 75 (29.6%) had moderate to severe hyponatraemia. Potential causes were documented in 101 (40%). Patients with moderate to severe hyponatraemia were five times more likely to have a cause of hyponatraemia documented (p<0.01). Medications were the commonest documented cause of hyponatraemia (31.7%). Hydrochlorothiazide use was attributed in 25 (78.1%) of 32 with medication-associated hyponatraemia. Repeat renal profile (89%) was the commonest management of hypotonic hyponatraemia. CONCLUSION: Whilst hyponatraemia was common in the clinic setting, many cases were not acknowledged and had no clear management strategies. In view of mild hyponatraemia has deleterious consequences, future studies should determine whether appropriate management of mild hyponatraemia will lead to clinical improvement.

Addition of sodium criterion to SOAR stroke score.

OBJECTIVES: To examine the usefulness of including sodium (Na) levels as a criterion to the SOAR stroke score in predicting inpatient and 7-day mortality in stroke. MATERIALS AND METHODS: Data from the Norfolk and Norwich University Hospital Stroke & TIA register (2003-2015) were analysed. Univariate and then multivariate models controlling for SOAR variables were used to assess the association between admission sodium levels and inpatient and 7-day mortality. The prognostic ability of the SOAR and SOAR Na scores for mortality outcomes at both time points were then compared using the Area Under the Curve (AUC) values from the Receiver Operating Characteristic curves. RESULTS: A total of 8493 cases were included (male=47.4%, mean (SD) 77.7 (11.6) years). Compared with normonatremia (135-145 mmol/L), hypernatraemia (>145 mmol/L) was associated with inpatient mortality and moderate (125-129 mmol/L) and severe hypontraemia (<125 mmol/L) with 7-day mortality after adjustment for stroke type, Oxfordshire Community Stroke Project classification, age, prestroke modified Rankin score and sex. The SOAR and SOAR-Na scores both performed well in predicting inpatient mortality with AUC values of .794 (.78-.81) and .796 (.78-.81), respectively. 7-day mortality showed similar results. Both scores were less predictive in those with chronic kidney disease (CKD) and more so in those with hypoglycaemia. CONCLUSION: The SOAR-Na did not perform considerably better than the SOAR stroke score. However, the performance of SOAR-Na in those with CKD and dysglycaemias requires further investigation.

Non-Pharmacological Interventions to Prevent or Treat Delirium in Older Patients: Clinical Practice Recommendations The SENATOR-ONTOP Series.

DESCRIPTION: The ONTOP project aims to undertake a literature search of systematic reviews concerning evidence-based non-pharmacological interventions of prevalent medical conditions affecting older people, including delirium. OBJECTIVES: To develop explicit and transparent recommendations for non-pharmacological interventions in older subjects at risk of developing delirium, as well as in older subjects with delirium, based on the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach to rating the quality of evidence and the strength of recommendations. METHODS: A multidisciplinary panel was constituted comprising geriatricians, research nurse and a clinical epidemiologist. The panel developed a systematic overview of non-pharmacological interventions to prevent or treat delirium. The GRADE approach was used to rate the evidence and to formulate recommendations. RESULTS: The critical outcomes were delirium incidence, for delirium prevention, and delirium improvement and functional status, for delirium treatment. The non-pharmacological interventions were identified and categorized as multicomponent and single component. Strong recommendations in favor of multicomponent interventions to prevent delirium, in surgical or medicals wards, were formulated. In the latter case the evidence applied to older patients at intermediate - high risk of developing delirium. Weak recommendations, to prevent delirium, were formulated for multicomponent interventions provided by family members (medical ward), staff education (medical ward), ear plugs (intensive care unit), reorientation protocol (intensive care unit), and the use of a software to perform drug review. Weak recommendations were provided for the use of multicomponent interventions to prevent delirium in medical wards in patients not selected according to the risk of delirium. Strong recommendations not to use bright light therapy to prevent delirium in intensive care unit settings were articulated. Weak recommendations not to use music therapy to prevent delirium for patients undergoing surgical interventions were specified. The ability to make strong recommendations was limited by the low quality of evidence and the presence of uncertainty. Moreover, weak recommendations were provided for the use of multicomponent interventions to treat delirium of older patients (medical wards). CONCLUSIONS: Overall, the panel developed 12 recommendations for the delivery of non-pharmacological interventions to older patients at risk of developing or, with delirium.

Bioelectrical impedance analysis is more accurate than clinical examination in determining the volaemic status of elderly patients with fragility fracture and hyponatraemia.

OBJECTIVES: Management of hyponatraemia depends crucially on accurate determination of volaemic (hydration) status but this is notoriously challenging to measure in older people. Bioelectrical impedance analysis (BIA) provides a validated means of determining total body water (TBW), but its clinical utility in determining volaemic status in hyponatraemia has never been tested. This study assessed the utility of BIA in the clinical management of hyponatraemia in elderly patients with fragility fractures (EPFF), a group at high risk of hyponatraemia. DESIGN: Prospective observational study of consenting patients ≥65 years with fragility fractures (N=127). SETTING: University teaching hospital in Scotland. PARTICIPANTS: Patients ≥665 years with fragility fractures with capacity to consent to participation. MEASUREMENTS: BIA and standard clinical examination procedures (jugular venous distension, skin turgor, mouth and axillary moistness, peripheral oedema, capillary refill time, overall impression) were performed daily throughout each participant's hospital stay. Volaemic status of hyponatraemia was determined by an expert panel using clinical data (history, examination, nursing observations and laboratory tests) blinded to TBW readings. Cohen's kappa was calculated to assess the level of agreement between the expert panel and both BIA and standard clinical examination measures in determining the volaemic state of hyponatraemia. RESULTS: 26/33 (79%) cases of hyponatraemia had sufficient clinical information to allow determination of volaemic status by BIA. There was moderate level of agreement between BIA and the expert panel, kappa 0.52 (p<.001). All kappa values for standard clinical assessments of volaemic status neared zero, indicating nil to slight agreement. CONCLUSION: BIA outperformed all aspects of the standard clinical examination in determining the volaemic status of hyponatraemic EPFF, suggesting it may be useful in clinical practice.

Non-psychiatric comorbidity associated with Alzheimer's disease.

The burden of medical comorbidity in individuals with Alzheimer's disease is greater than that observed in matched individuals without dementia. This has important implications for all clinicians and healthcare providers who deal with this common condition. The prevalence of vascular risk factors and vascular disease is particularly high. Additionally, associations with a number of other chronic medical conditions have been described, including thyroid disorders, sleep apnoea, osteoporosis and glaucoma. This review gives an overview of evidenced medical (non-psychiatric) comorbidity associated with Alzheimer's disease and briefly explores the underlying mechanisms that may account for these associations.

Age, co-morbidity and poor mobility: no evidence of predicting in-patient death and acute hospital length of stay in the oldest old.

BACKGROUND: The oldest old (aged over 90 years) are the fastest growing section of the UK population. Limited data exist regarding the effect of age, location, co-morbidity and physical performance status on outcome of acute illness in this age group. METHODS: We performed a prospective study in people aged ≥ 90 years using hospital audit data in three hospitals in England and Scotland. We examined the characteristics of those admitted over three consecutive calendar months and calculated risk ratios of death and prolonged length of acute hospital stay (>7 days). RESULTS: A total of 419 patients were included in this study (68% female, median age 93 years). There were similarities in presentation and diagnoses, but patients in Scotland (n = 164) were more likely to be admitted from sheltered housing or nursing homes than those in England (n = 255). Patients in England were significantly less likely to be able to mobilize < 10 m (41 vs. 34%, P < 0.001) but had lower prevalence of hypertension (40 vs. 55%, P = 0.02), ischaemic heart disease (30% vs. 45%, P = 0.02) and fewer prescribed medications (median 2 vs. 3, P < 0.001). Mortality was similar for the England and Scotland centres (P = 0.98). Previously recognized risk factors for death following hospital admission and length of stay e.g. older age, higher number of co-morbidities and poor mobility were not predictive in this study. CONCLUSION: The 'oldest old' should not be considered as a homogenous group and findings from single-centre studies involving this age group may not be generalizable. We found no conclusive evidence that patient-related factors predict outcome in this age group in acute medical admission settings.

Volaemic assessment of the elderly hyponatraemic patient: reliability of clinical assessment and validation of bioelectrical impedance analysis.

BACKGROUND: Hyponatraemia is the commonest electrolyte disturbance of hospital inpatients. Assessment of volaemic status is an important part of diagnosis and management. AIM: To determine reliability of clinical assessment of volaemic state by assessing inter-observer variability of clinical measures of volaemic state. To assess validity of bioelectrical impedance analysis as a tool to measure total body water in elderly hyponatraemic patients. DESIGN: Observational study conducted in a Department of Medicine for the Elderly. METHODS: Hospital inpatients >65 years old (n=22) with serum sodium concentration <130 mmol/l were included. Two assessors determined volaemic state on two occasions 72 h apart. Level of agreement between observers was determined on each occasion. Total body water estimation was undertaken with bioelectrical impedance analysis and measurement of dilution of deuterium oxide. Correlation between these two measures was then analysed. RESULTS: Cohen's κ for agreement between two observers for overall assessment of volaemic state was 0.59 (P<0.01). Values for agreement between individual clinical markers of volaemic state ranged between 0.16 and 0.45. Pearson correlation coefficient (r) for correlation between estimation of total body water undertaken by bioelectrical impedance analysis and by measurement of dilution of deuterium oxide was 0.69 (P<0.001). CONCLUSION: There was moderate inter-observer agreement of overall clinical volaemic assessment of elderly hyponatraemic patients. Total body water estimation by bioelectrical impedance analysis correlates well with estimation by measurement of dilution of deuterium oxide, providing a potentially useful tool to improve the management of the elderly hyponatraemic patient.

Hormonal responses to a single session of wholebody vibration exercise in older individuals.

OBJECTIVE: Whole-body vibration (WBV) has been recently suggested as an alternative form of exercise. In this study, the acute effects of a single session of WBV exercise on anabolic hormones in aged individuals were analysed. DESIGN: A randomised cross-over trial design was used. SETTINGS: Geriatrics Department, Woodend Hospital. PARTICIPANTS: 20 individuals (9 men and 11 women; median age 70 years (range 66 to 85 years) volunteered in the experiment. Interventions Isometric squat on a platform with vibration or no vibration (control) conditions. MAIN OUTCOME MEASUREMENTS: Plasma cortisol, testosterone, growth hormone (GH) and insulin-like growth factor 1 (IGF-1) were measured before, immediately after, and 1 and 2 h after the interventions. REPORTS: A significant difference between treatments (p<0.001) and a time x treatment interaction (p<0.05) was found in IGF-1 levels. Cortisol levels were shown not to be significantly different between treatments (p = 0.43), but a difference over time (p<0.001) and a time6 treatment interaction (p<0.05) were identified. No significant differences were identified in GH and testosterone levels. CONCLUSIONS: As shown by the results of the study, 5 min of WBV exercise characterised by static squat with a frequency of 30 Hz can be performed by older individuals without apparent signs of stress and/or fatigue. Furthermore, WBV produced an acute increase in the circulating levels IGF-1 and cortisol greater than that observed following the same exercise protocol conducted without vibration.

Risk stratification in acute coronary syndromes--does the TIMI risk score work in unselected cases?

BACKGROUND: Management of patients with an acute coronary syndrome (ACS) requires accurate risk stratification to guide appropriate therapy. AIM: To assess the utility of the TIMI risk score in stratifying patients with possible ACS in routine clinical practice. DESIGN: Prospective observational study. METHODS: We recruited 869 consecutive patients with a diagnosis of possible ACS attending the acute medical receiving unit of a district general hospital. The main outcome measures were recurrent myocardial infarction, urgent revascularization, and all-cause mortality. TIMI risk score was calculated for each patient, and each was also assigned a risk group based on electrocardiogram (ECG) changes and troponin levels only. After follow-up, Cox univariate and multivariate regression was used to evaluate the influence of potential risk factors on duration of event-free survival, and likelihood ratio tests to assess the fit of the models. RESULTS: Increasing TIMI risk score was associated with increased risk of events (p<0.001), as was higher risk group from ECG plus troponin stratification (p<0.001). The likelihood ratio comparison favoured the TIMI risk score (difference 13.910, 5 degrees of freedom, p = 0.016). DISCUSSION: The TIMI risk score is a valid tool for risk stratification in unselected cases with possible acute coronary syndrome. It is superior to ECG changes and troponin alone, although this simpler method also achieves good risk stratification.