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.

OBJECTIVE:This study aimed to evaluate the association between polypharmacy and delirium, the association of specific drug categories with delirium, and the differences in drug-delirium association between medical and surgical units and according to dementia diagnosis.METHODS:Data were collected during 2 waves of Delirium Day, a multicenter delirium prevalence study including patients (aged 65 years or older) admitted to acute and long-term care wards in Italy (2015-2016); in this study, only patients enrolled in acute hospital wards were selected (n = 4,133). Delirium was assessed according to score on the 4 "A's" Test. Prescriptions were classified by main drug categories; polypharmacy was defined as a prescription of drugs from 5 or more classes.RESULTS:Of 4,133 participants, 969 (23.4%) had delirium. The general prevalence of polypharmacy was higher in patients with delirium (67.6% vs 63.0%, P = .009) but varied according to clinical settings. After adjustment for confounders, polypharmacy was associated with delirium only in patients admitted to surgical units (OR = 2.9; 95% CI, 1.4-6.1). Insulin, antibiotics, antiepileptics, antipsychotics, and atypical antidepressants were associated with delirium, whereas statins and angiotensin receptor blockers exhibited an inverse association. A stronger association was seen between typical and atypical antipsychotics and delirium in subjects free from dementia compared to individuals with dementia (typical: OR = 4.31; 95% CI, 2.94-6.31 without dementia vs OR = 1.64; 95% CI, 1.19-2.26 with dementia; atypical: OR = 5.32; 95% CI, 3.44-8.22 without dementia vs OR = 1.74; 95% CI, 1.26-2.40 with dementia). The absence of antipsychotics among the prescribed drugs was inversely associated with delirium in the whole sample and in both of the hospital settings, but only in patients without dementia.CONCLUSIONS:Polypharmacy is significantly associated with delirium only in surgical units, raising the issue of the relevance of medication review in different clinical settings. Specific drug classes are associated with delirium depending on the clinical setting and dementia diagnosis, suggesting the need to further explore this relationship.

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 12-lead ECG was obtained and corrected QT was calculated by the Bazetts 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.

ObjectivesTo determine whether emergency department (ED) length of stay before ward admission is associated with incident delirium in older adults.DesignProspective cohort study.SettingHospital.ParticipantsIndividuals aged 75 and older without delirium at ED entry, coma, aphasia, stroke, language barrier, psychiatric disorder, or alcohol abuse (N=330).MeasurementsOn 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 3days after ward admission, the presence of delirium (defined as 1 delirium episodes within 72hours) 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.ResultsED length of stay longer than 10hours (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.ConclusionED length of stay longer than 10hours was associated with greater risk of delirium in hospitalized older adults, after adjusting for age and cognitive impairment.

Journal of the American Geriatrics SocietyVolume 64, Issue 9 p. e18-e19 Letters to the EditorFree Access Postdischarge Clinical Outcomes in Older Medical Patients with an Emergency Department Stay–Associated Delirium Onset Mario Bo MD, PhD, Mario Bo MD, PhD Struttura Complessa a Direzione Universitaria Geriatria e Malattie Metaboliche dell'Osso, Città della Salute e della Scienza-Molinette, Torino, ItalySearch for more papers by this authorMartina Bonetto MD, Martina Bonetto MD Struttura Complessa Geriatria e Cure Intermedie, Azienda Sanitaria Ospedaliera Santa Croce e Carle di Cuneo, Cuneo, ItalySearch for more papers by this authorGiuliana Bottignole MD, Giuliana Bottignole MD Struttura Complessa a Direzione Universitaria Geriatria e Malattie Metaboliche dell'Osso, Città della Salute e della Scienza-Molinette, Torino, ItalySearch for more papers by this authorPaola Porrino MD, Paola Porrino MD Struttura Complessa a Direzione Universitaria Geriatria e Malattie Metaboliche dell'Osso, Città della Salute e della Scienza-Molinette, Torino, ItalySearch for more papers by this authorEleonora Coppo MD, Eleonora Coppo MD Struttura Complessa a Direzione Universitaria Geriatria e Malattie Metaboliche dell'Osso, Città della Salute e della Scienza-Molinette, Torino, ItalySearch for more papers by this authorMichela Tibaldi MD, Michela Tibaldi MD Struttura Complessa a Direzione Universitaria Geriatria e Malattie Metaboliche dell'Osso, Città della Salute e della Scienza-Molinette, Torino, ItalySearch for more papers by this authorGiacomo Ceci MD, Giacomo Ceci MD Struttura Complessa a Direzione Universitaria Geriatria e Malattie Metaboliche dell'Osso, Città della Salute e della Scienza-Molinette, Torino, ItalySearch for more papers by this authorSilvio Raspo MD, Silvio Raspo MD Struttura Complessa Geriatria e Cure Intermedie, Azienda Sanitaria Ospedaliera Santa Croce e Carle di Cuneo, Cuneo, ItalySearch for more papers by this authorGiorgetta Cappa MD, Giorgetta Cappa MD Struttura Complessa Geriatria e Cure Intermedie, Azienda Sanitaria Ospedaliera Santa Croce e Carle di Cuneo, Cuneo, ItalySearch for more papers by this authorGiuseppe Bellelli MD, Giuseppe Bellelli MD Dipartimento di Scienze della Salute, Università Milano-Bicocca, Milan, Italy Acute Geriatric Unit, San Gerardo Hospital, Monza, ItalySearch for more papers by this author Mario Bo MD, PhD, Mario Bo MD, PhD Struttura Complessa a Direzione Universitaria Geriatria e Malattie Metaboliche dell'Osso, Città della Salute e della Scienza-Molinette, Torino, ItalySearch for more papers by this authorMartina Bonetto MD, Martina Bonetto MD Struttura Complessa Geriatria e Cure Intermedie, Azienda Sanitaria Ospedaliera Santa Croce e Carle di Cuneo, Cuneo, ItalySearch for more papers by this authorGiuliana Bottignole MD, Giuliana Bottignole MD Struttura Complessa a Direzione Universitaria Geriatria e Malattie Metaboliche dell'Osso, Città della Salute e della Scienza-Molinette, Torino, ItalySearch for more papers by this authorPaola Porrino MD, Paola Porrino MD Struttura Complessa a Direzione Universitaria Geriatria e Malattie Metaboliche dell'Osso, Città della Salute e della Scienza-Molinette, Torino, ItalySearch for more papers by this authorEleonora Coppo MD, Eleonora Coppo MD Struttura Complessa a Direzione Universitaria Geriatria e Malattie Metaboliche dell'Osso, Città della Salute e della Scienza-Molinette, Torino, ItalySearch for more papers by this authorMichela Tibaldi MD, Michela Tibaldi MD Struttura Complessa a Direzione Universitaria Geriatria e Malattie Metaboliche dell'Osso, Città della Salute e della Scienza-Molinette, Torino, ItalySearch for more papers by this authorGiacomo Ceci MD, Giacomo Ceci MD Struttura Complessa a Direzione Universitaria Geriatria e Malattie Metaboliche dell'Osso, Città della Salute e della Scienza-Molinette, Torino, ItalySearch for more papers by this authorSilvio Raspo MD, Silvio Raspo MD Struttura Complessa Geriatria e Cure Intermedie, Azienda Sanitaria Ospedaliera Santa Croce e Carle di Cuneo, Cuneo, ItalySearch for more papers by this authorGiorgetta Cappa MD, Giorgetta Cappa MD Struttura Complessa Geriatria e Cure Intermedie, Azienda Sanitaria Ospedaliera Santa Croce e Carle di Cuneo, Cuneo, ItalySearch for more papers by this authorGiuseppe Bellelli MD, Giuseppe Bellelli MD Dipartimento di Scienze della Salute, Università Milano-Bicocca, Milan, Italy Acute Geriatric Unit, San Gerardo Hospital, Monza, ItalySearch for more papers by this author First published: 18 August 2016 https://doi.org/10.1111/jgs.14276Citations: 1AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat To the Editor: Current evidence suggests that the most successful strategy to prevent delirium includes a multicomponent approach to modifiable risk factors.1 Identification of correctable hospitalization-related conditions that predispose to delirium might be useful in daily clinical practice.2, 3 It was recently found that an emergency department (ED) length of stay of longer than 10 hours was associated with greater risk of delirium in older hospitalized adults.4 However, whether occurrence of delirium in these individuals results in greater risk of adverse outcomes was not assessed. The current study prospectively evaluated whether individuals with delirium onset within 72 hours after ward admission are more likely to die or be rehospitalized after discharge than those without. Four geriatric postgraduate students (GC, MT, EC, MB) screened individuals aged 75 and older consecutively admitted to the ED of two university teaching hospitals (Città della Salute e della Scienza, Molinette, Torino; Azienda Ospedaliera Santa Croce e Carle, Cuneo, Piemonte, Northern Italy) for the presence of delirium using the 4AT, a rapid assessment test for delirium;5 at the same time, two senior geriatricians (MZ, MB) supervised the administration of 4AT at ED arrival and diagnosed delirium according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.6 The 4AT has recently been validated in older hospitalized adults.5 In the validation study, which included the short Confusion Assessment Method (CAM), a score greater than 4 out of 12 on the 4AT had sensitivity of 89.7% and sensitivity of 84.1% for delirium (sensitivity of 83.3% and sensitivity of 91.3% in individuals without dementia, sensitivity of 94.1% and sensitivity of 64.9% in individuals with dementia). The areas under the receiver operating characteristic curves for delirium diagnosis were 0.93 in the whole population, 0.92 in individuals without dementia, and 0.89 in individuals with dementia, suggesting good specificity for delirium in a population without dementia and good sensitivity to delirium in a population with dementia. Individuals without delirium and without exclusion criteria at ED entry who were admitted to an acute medical or geriatric ward were assessed daily for the presence of delirium, which was diagnosed in 52 of 330 (15.8%) during the first 72 hours after admission; ED stay of longer than 10 hours was found to be associated with significantly greater risk of delirium. The current study compared the 6-month postdischarge incidence of a composite end-point (all-cause death and rehospitalization) in individuals who developed delirium within the first 72 hours with that of all other discharged individuals. Death and rehospitalization were ascertained through telephone interview (participants or proxy respondents were used as the primary source of information) and medical chart review. Clinical variables associated with the composite end-point were identified using the Mann–Whitney U test and chi-square test for categorical variables. Multivariate analysis was used to test the association between delirium associated with an ED stay and the composite end-point. Thirty of the 330 individuals admitted died in the hospital (9.1%, including 13 of 52 with early delirium), leaving a sample of 300, including 39 with delirium onset within the first 72 hours after ward admission and 14 with later delirium onset. The main demographic and clinical variables of the individuals are reported in Table 1. At 6-month follow-up, 38 of 300 discharged participants (12.7%) had died, and 99 (33.3%) had had at least one rehospitalization. Of participants with delirium onset within 72 hours, all-cause death and rehospitalization rates were not significantly more frequent, and the composite end-point (n = 28, 71.8%) was significantly more frequent than in other participants (n = 102, 28.2%) (P < .001). Delirium occurrence within 72 hours (odds ratio (OR) = 1.43, 95% confidence interval (CI) = 1.13–1.67), functional dependence (OR = 1.37, 95% CI = 1.05–1.71), greater Cumulative Illness Rating Scale severity (OR = 1.18, 95% CI = 1.08–1.89), low hematocrit (OR = 0.79, 95% CI = 0.53–0.98) and serum albumin levels (OR = 0.69, 95% CI = 0.38–0.97) were significantly associated with greater incidence of the composite end-point. Table 1. Main Demographic and Clinical Variables in the Overall Sample of Discharged Individuals (N = 300) Variable Value Age, median (IQR) 81.9 (78.3–86.9) Male, n (%) 147 (49.0) Location, median (IQR) Home 258 (86.1) Nursing home 42 (13.9) Number of drugs/d, n (%) <5 78 (26.0) 5–10 195 (65.0) ≥11 27 (9.0) ADL score, median (IQR) 2.0 (0.0–5.0) Functional dependence (ADL score ≥3), n (%) 163 (54.3) Instrumental ADL score, median (IQR) 7.0 (4.0–10.0) SPMSQ score, median (IQR) 4.0 (1.0–7.0) Moderate to severe cognitive impairment (SPMSQ score ≥6), n (%) 103 (34.3) CIRS score, median (IQR) 3.0 (2.0–5.0) Severe comorbidity (CIRS score ≥5), n (%) 91 (30.3) Hematocrit, %, mean ± SD 41.3 ± 3.7 Serum creatinine, mg/dL, mean ± SD 1.1 ± 0.6 Serum albumin, g/dL, mean ± SD 3.4 ± 0.3 Length of stay in ward, days, median (IQR) 10.0 (5.6–15.1) IQR = interquartile range; ADL = activity of daily living; SPMSQ = Short Portable Mental Status Questionnaire; CIRS = Cumulative Illness Rating Scale; SD = standard deviation. These results provide evidence that individuals who experience delirium within 72 hours after ward admission have a greater risk of death and rehospitalization; the association between delirium occurrence and the composite end-point remained significant after multivariate adjustment. In keeping with previous studies that have reported greater postdischarge mortality and worse clinical outcomes in individuals who develop delirium during a hospital stay,7-10 these findings add to the current evidence demonstrating that ED length of stay, by increasing the risk of delirium onset, might contribute to postdischarge death and rehospitalizations. Therefore, whether interventions designed to shorten the length of ED stay (or to make it more comfortable) may reduce the incidence of delirium in older vulnerable adults and result in a better overall prognosis, including lower mortality and rehospitalization rates, should be evaluated. Acknowledgments The ethics committees approved the research protocol, and written consent was obtained from all participants. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: Mario Bo: expert geriatrician, writing the manuscript. Martina Bonetto: study design. Bottignole, Porrino, Coppo, Tibaldi, Ceci: data collection. Raspo: statistical analysis. Cappa: expert geriatrician. Bellelli: reviewer. Sponsor's Role: None. References 1Inouye SK, Holford TR, Cooney LM Jr et al. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med 1999; 340: 669– 676. 2Carpenter CR, Platts-Mills TF. Evolving prehospital, emergency department, and “inpatient” management models for geriatric emergencies. Clin Geriatr Med 2013; 29: 31– 47. 3Carpenter CR, Bromley M, Caterino JM et al. Optimal older adult emergency care: Introducing multidisciplinary geriatric emergency department guidelines from the American College of Emergency Physicians, American Geriatrics Society, Emergency Nurses Association, and Society for Academic Emergency Medicine. J Am Geriatr Soc 2014; 62: 1360– 1363. 4Bo M, Bonetto M, Bellelli G et al. Length of stay in the emergency department and occurrence of delirium in older medical patients. J Am Geriatr Soc 2015; 63 doi: 10.1111/jgs.14103 5Bellelli G, Annoni G, MacLullich AMJ et al. Validation of the 4AT, a new instrument for rapid delirium screening: A study in 234 hospitalized older people. Age Ageing 2014; 43: 496– 502. 6 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th Ed. Washington, DC: American Psychiatric Association, 2013. 7Siddiqi N, House A, Holmes J. Occurrence and outcome of delirium in medical in-patients: A systematic literature review. Age Ageing 2006; 35: 350– 364. 8McCusker J, Cole M, Abrahamovicz M et al. Delirium predicts 12 month mortality. Arch Intern Med 2002; 162: 457– 463. 9McAvay GJ, van Ness PH, Bogardus ST et al. Older adults discharged from hospital with delirium: One year outcomes. J Am Geriatr Soc 2006; 54: 1245– 1250. 10Isaia G, Astengo M, Aimonino Ricauda N et al. Delirium in elderly home-treated patients: A prospective study with 6-month follow-up. Am Aging Assoc 2009; 31: 109– 117. Citing Literature Volume64, Issue9September 2016Pages e18-e19 ReferencesRelatedInformation