Impaired hydration status in acutely admitted older patients: prevalence and impact on mortality.

BACKGROUND: impaired hydration is common in the older people, however studies of its effects on outcome in the acute setting are limited. OBJECTIVES: to assess (i) the prevalence of impaired hydration, (ii) its relationship with laboratory markers of altered hydration and with (iii) short- and long-term mortality. DESIGN: retrospective cohort study. SETTING: University Hospital-Internal Medicine Department. SUBJECTS: a total of 5,113 older patients consecutively acutely admitted from October 2015 to July 2016. METHODS: according to calculated serum osmolarity at admission hydration status was stratified in: low osmolarity (<275 mmol/L), euhydration (275-295 mmol/L), impending (296-300 mmol/L) and current dehydration (>300 mmol/L). Relationships with serum sodium, potassium, glucose, urea, estimated glomerular filtration rate (eGFR), haematocrit, urea/creatinine ratio (Urea/Cr) and urine specific gravity (USG) were determined. Charlson Comorbidity Index, Modified Early Warning Score, Glasgow Prognostic Score, Norton score and Nutritional Risk Screening-2002 were calculated. RESULTS: current and impending dehydration, euhydration and low-osmolarity were detected in 51.7, 17.1, 28.5 and 2.7% of the patients, respectively. Osmolarity correlated with urea (r = 0.846). Associations with serum sodium, creatinine, eGFR and urea/Cr were low but significant, being negligible that with USG and haematocrit. Serum sodium and urea increased in the transition from low- to high-osmolarity (P < 0.001 in all pairwise comparisons). In multivariate modelling current dehydration, functional dependence, clinical instability and high nutritional risk were associated (P < 0.001) with reduced short- and long-term survival. CONCLUSIONS: impaired hydration is common in older people acutely admitted to medical care and is associated with poor outcome. Early assessment of calculated serum osmolarity is mandatory to target dehydration and hypoosmolar disorders.

Stage-related implications of community-acquired pressure injuries for the acute medical inpatients.

AIMS: To analyse the prevalence of any-stage pressure injuries at hospital admission and their impact on short-, mid- and late-term mortality. Patient characteristics associated with pressure injuries and the impact on hospital costs were also investigated. BACKGROUND: In medical patients acutely admitted to hospital, no study analysed the presence of pre-existing pressure injuries and the related short- and long-term mortality according to the overall stages of severity thereof. DESIGN: Retrospective cohort study following the STROBE guideline. METHODS: In a population of 7217 acute medical inpatients, the presence and staging of pressure injuries were assessed at hospital admission. The impact of pressure injury on 30-, 180- and 365-day mortality was analysed by multivariate Cox regression models. RESULTS: The prevalence of community-acquired pressure injuries was 14.9% (stage-1: 8.1%; stage-2: 3.5%; stage-3: 1.6%; stage-4: 1.1%; unstageable: 0.5%). Hemiplegia/paraplegia, anaemia, poor functional status, high nutritional risk, clinical instability and systemic inflammatory response, but not hydration status, were found to be associated with the occurrence of stage-2-and-above pressure injuries. An increasing difference was found in Diagnosis-Related Groups (DRG) weight according to pressure injury stages. A distinct and progressively increasing risk-of-death for any-stage pressure injury was shown after 365-days. A significantly increased mortality risk for all considered time intervals was found for unstageable and stage-4 pressure injuries. CONCLUSIONS: In acute medical inpatients, the presence of community-acquired pressure injuries is part of a multidimensional clinical complexity. The presence and staging of pressure injuries have an independent dramatic impact on of early-to-late mortality and hospital costs. RELEVANCE TO CLINICAL PRACTICE: This study documented as community-acquired pressure injuries are highly prevalent and represents an independent predictor of outcomes in strict dependence of the progression of thereof stage. The presence of community-acquired pressure injuries should be interpreted as a critical marker of frailty and increased vulnerability.

Prediction of early- and long-term mortality in adult patients acutely admitted to internal medicine: NRS-2002 and beyond.

BACKGROUND & AIMS: In hospitalized patients malnutrition is a risk factor for adverse clinical outcomes. The Nutritional Risk Screening 2002 (NRS-2002) represents a quick and simple tool to identify malnutrition risk in this population. No study tested the predictive power of NRS-2002 on mortality adjusting for confounders related to patient's complexity, thus considering conditions such as functional status, illness-related severity and inflammation. The aim of this study was to explore the independent prognostic power and the relative weight of NRS-2002 screening tool to predict inhospital and post-discharge (up to 1 year) mortality, adjusting for variables representing the non-disease specific multidimensional complexity of patients admitted to Internal Medicine wards. METHODS: Retrospective observational study including 5698 consecutive patients acutely admitted to an Internal Medicine Department. Logistic regression models were run to test the predictive power of the NRS-2002 on patient mortality at different time intervals, adjusted for age, sex, Charlson comorbidity index, Glasgow Prognostic Score (GPS), BUN/creatinine ratio, Modified Early Warning Score (MEWS), and Norton index. The performance of the logistic models in predicting mortality was measured through the c-statistic. The different time of death between patients scored upon admission as NRS-2002 < 3 or ≥3 was evaluated through crude Kaplan-Meier curves and multivariate Cox proportional hazard analysis. RESULTS: Patients classified at high malnutrition risk (NRS-2002 ≥ 3) showed a higher and earlier mortality (Log-rank test: p < 0.001) compared to subjects in the NRS-2002 "low-risk" group. NRS-2002 ≥ 3 was an independent significant (p < 0.01) predictor of mortality in logistic regression at every time interval. Among the considered covariates, Charlson index, GPS and Norton scale showed a steadily higher OR than NRS-2002 in predicting both early and late mortality. The multivariate models demonstrated a very good discrimination for hospital and mid-term (up to 90 days) mortality. Being classified at risk for malnutrition (NRS-2002 ≥ 3) on admission independently increased the risk of one-year death (HR = 1.431; 95% CI: 1.277-1.603; p < 0.001) compared to the patients who were scored at low malnutrition risk. CONCLUSIONS: Malnutrition risk identified upon hospital admission by NRS-2002 independently contributes to early and late mortality in a population including a majority of elderly. However, risk of malnutrition has to be considered according to other factors related to comorbidities, functional status, illness severity and inflammation which reciprocally interact, concurring at worsening patient's outcome.