OBJECTIVES: To identify prognostic factors that are independently predictive of in‐hospital mortality in older patients hospitalized in a medical intensive care unit (MICU). DESIGN: Prospective cohort study. SETTING: A MICU in an Italian university hospital. PARTICIPANTS: Patients aged 65 and older consecutively admitted to the MICU directly from the first‐aid unit. MEASUREMENTS: Upon admission, the following variables were examined: demographics, clinical history (diabetes mellitus, active neoplasm, cognitive impairment, immobilization, pressure ulcers, use of nutritional support, home oxygen therapy), physiopathology (Acute Physiology and Chronic Health Evaluation (APACHE) II), and cognition/function (activity of daily living (ADL), instrumental activity of daily living (IADL), Short Portable Mental Status Questionnaire (SPMSQ)). The vital status of the patient at the end of hospitalization was recorded. RESULTS: Over a period of 10 months, 659 patients were recruited (mean age ± standard deviation = 76.6 ± 7.5; 352 men and 307 women). There were 97 deaths (14.71%). The following factors proved to be significantly associated with in‐hospital mortality: old age, low body mass index (BMI) values, low values of albumin, high scores on APACHE II, functional impairment (ADL, IADL), cognitive impairment (SPMSQ), history of cognitive deterioration, history of confinement to bed, and presence of pressure ulcers. Using multivariate analysis, the following variables were independently predictive of in‐hospital mortality: lack of independence in ADLs (P < .001), moderate‐to‐severe cognitive impairment on SPMSQ (P < .001), score on APACHE II (P = .002), and low BMI values (P = .031). CONCLUSION: The prognosis of older patients hospitalized in medical intensive care units depends not only on the acute physiological impairments, but also on a series of preexisting conditions, such as loss of functional independence, severe and moderate cognitive impairment, and low BMI.

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Objectives: To evaluate whether home treatment of elderly patients with acute uncomplicated first ischemic stroke is associated with different mortality rates and clinical outcomes from those of patients treated on a general medical ward (GMW). Design: Randomized, controlled, single‐blind trial. Setting: S. Giovanni Battista Hospital of Turin. Participants: One hundred twenty elderly patients admitted to the emergency department of the hospital with first acute ischemic stroke were randomized to home treatment from a geriatric home hospitalization service (GHHS) or to GMW treatment. Measurement: Main outcome was cumulative survival at 6 months in the two groups. Residual functional impairment, neurological deficit, depression, morbidity, and admission to rehabilitation and long‐term care facilities were considered as secondary outcomes in survivors. Results: One hundred twenty patients (mean age 82; 54 men and 66 women) were enrolled (60 in each study arm). The cumulative proportion of cases surviving at 6 months was 0.65 in the GHHS group and 0.60 in GMW group (log‐rank test P=.53). Functional and neurological parameters were significantly improved in both GHHS and GMW patients, without significant differences between the two groups. Depression score was significantly better in home‐treated patients (P<.001), who were more likely to remain at home at 6 months than hospital‐treated patients and had a lower rate of select medical complications. Conclusion: Home‐treated elderly patients with ischemic stroke have better depressive scores and lower rates of admission to nursing homes. These results should prompt further studies to evaluate home hospitalization for elderly stroke patients.

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Rationale: Malnutrition often affects elderly patients and significantly contributes to the reduction in healthy life expectancy, causing high morbidity and mortality. In particular, protein malnutrition is one of the determinants of frailty and sarcopenia in elderly people. Methods:To investigate the role of amino acid supplementation in senior patients we performed an openlabel randomized trial and administered a peculiar branched-chain amino acid enriched mixture (BCAAem) or provided diet advice in 155 elderly malnourished patients. They were followed for 2 months, assessing cognitive performance by Mini Mental State Examination (MMSE), muscle mass measured by anthropometry, strength measure by hand grip and performance measured by the Timed Up and Go (TUG) test, the 30 seconds Chair Sit to Stand (30-s CST) test and the 4 meters gait speed test. Moreover we measured oxidative stress in plasma and mitochondrial production of ATP and electron flux in peripheral blood mononuclear cells.Results: Both groups improved in nutritional status, general health and muscle mass, strength and performance; treatment with BCAAem supplementation was more effective than simple diet advice in increasing MMSE (1.2 increase versus 0.2, p=0.0171), ATP production (0.43 increase versus -0.1, p=0.0001), electron flux (0.50 increase versus 0.01, p<0.0001) and in maintaining low oxidative stress. The amelioration of clinical parameters as MMSE, balance, four meter walking test were associated to increased mitochondrial function.Conclusions: Overall, our findings show that sustaining nutritional support might be clinically relevant in increasing physical performance in elderly malnourished patients and that the use of specific BCAAem might ameliorate also cognitive performance thanks to an amelioration of mitochondria bioenergetics. KeywordsMalnutrition, elderly patients, branched-chain amino acids, muscle mass and strength, mitochondrial activity and biogenesis, oxidative stress. 30-s CST, seconds chair sit to stand test; ADL, activity of daily living; BCAAem, branched chain amino acid enriched mixture; BCAAs, branched chain amino acids; BMI, body mass index; CIRS, cumulative index rating scale; COX-1 and 4, cytochrome C oxidase 1 and 4; FOXO, forkhead box O; GAPDH, glyceraldehyde 3phosphate dehydrogenase; GDS, geriatric depression scale; GLM, linear regression models; MFN-1 and 2, mitofusin-1 and 2; MMSE, mini-mental state examination; MNA, mini nutritional assessment test; mTOR, mechanistic target of rapamycin; NRF-1, nuclear respiratory factor-1; NO, nitric oxide; OECD, organisation for economic co-operation and development; PBMCs, peripheral blood mononuclear cells; ROS, reactive oxygen species; RT-PCR, real time PCR; TBARs, thiobarbituric acid reactive substances; TFAM, mitochondrial transcription factor A; TUG, timed up and go test.

We aimed to evaluate the efficacy and safety of oxycodone/acetaminophen (O/A) and codeine/acetaminophen (C/A) vs. conventional therapy (CT) without opioids in older women suffering from osteoarthritis (OA)-related pain, sub-optimally responsive to prior conventional treatments. We performed a 6 week, randomized, single blind, controlled study in three nursing homes. We enrolled 154 women with painful OA. They were assigned to treatment with O/A (n=52) and C/A (n=52) vs. CT (n=50). We evaluated at baseline and at week 6: average pain in the last week (mean pain, MeP), pain at rest (RP), pain in movement (MP) (numeric rating scale, NRS); depressive symptoms (Beck Depression Inventory-II, BDI-II); functional status (activities of daily living, ADL) and cognitive status (mini mental state evaluation, MMSE). We considered the adverse events (AEs) in the study period. At week 6, MeP, RP and MP were significantly reduced in all three groups (p<0.001); compared to CT, O/A and C/A were associated with greater reductions in MeP (p<0.001 and p=0.004, respectively), in RP (p=0.028 and p=0.032, respectively) in MP (p<0.001 and p=0.002, respectively) and with significant improvement in BDI-II score (p=0.05 and p=0.04, respectively) and ADL value (p=0.04 and p=0.05, respectively). AE rates did not differ between groups.

Patients undergoing CE for symptomatic LICA disease appear to be at greater risk of cognitive decline than other subjects. These findings suggest that future studies should evaluate the effects on cognitive function of different timing for CE in patients with LICA and RICA disease.

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