Giuseppe Bellelli

Background: Hospital-based specialist palliative care (HSPC) teams are increasingly involved in the care of patients with advanced illness admitted to acute hospitals. However, a substantial proportion of patients referred to HSPC die during the index hospitalization. This study aims to assess the rate of in-hospital mortality among patients referred to an HSPC consultation service and to identify independent predictors of in-hospital death at the time of referral. Methods: We conducted a retrospective cohort study of adult patients referred to an in-hospital HSPC consultation service in a tertiary care hospital between 1st March 2022 and 31st December 2024. The primary outcome was death during the index hospitalization. Clinical and demographic variables recorded at referral were analysed using univariable and multivariable logistic regression. Model discrimination was assessed using the area under the receiver operating characteristic curve (AUC). Results: A total of 1,142 patients were included (median age 75 years; 56.7% male), of whom 343 (30.0%) died during index hospitalization. The strongest predictors of in-hospital death were bedridden status (OR 5.54), delirium (OR 2.73), assisted/chairbound status (OR 2.52), onco-hematological diagnosis (OR 1.87), and non-oncological diagnosis (OR 1.47). Dyspnea was associated with increased mortality, whereas fatigue and weight loss showed an inverse association. Model discrimination was satisfactory (AUC 0.769). Conclusions: Among patients referred to HSPC, in-hospital death was primarily driven by motor dependency, delirium, onco-hematological and non-oncological diagnoses and delayed referral. These findings suggest that simple bedside clinical and functional variables, routinely available at the time of first HSPC consultation, may support prognostic stratification of in-hospital mortality in acute care settings.

Aim: To compare diagnostic and therapeutic approaches to delirium across European countries with well-established (WE) versus less-developed (LE) geriatric medicine (GM), to identify similarities, differences and potential gaps in care. Methods: A cross-sectional online survey was conducted among European geriatricians via the European Geriatric Medicine Society and professional networks from July 2023 to March 2024. Responses on delirium diagnosis and management were analyzed quantitatively, with comparisons between WE and LDGM countries. Results: Of 196 hospital-based respondents, 79.1% were from WEGM countries and 20.9% from LDGM countries. Structured delirium screening was significantly more common in WEGM nations, especially in geriatric (88.4% vs 43.9%, p < 0.001) and orthopedic wards. Non-pharmacological strategies—such as hydration support (76.8% vs 52.5%, p = 0.002) and family involvement (81.5% vs 60.4%, p = 0.005)—were also more frequently used. Conversely, physical restraints were more commonly employed in LDGM countries (70.7% vs 41.4%, p < 0.001), as were pharmacological treatments, such as trazodone and quetiapine. Conclusion: Marked differences exist in delirium management across Europe, which may be linked at least in part to GM development, although confounding factors may exist, and causality cannot be assumed. WEGM countries appear to prioritize structured screening and non-pharmacological interventions, whereas LDGM countries rely more on pharmacological treatments. These findings highlight the need for standardized European guidelines to ensure equitable delirium care.

Background: End-of-life dreams and visions (ELDVs) are vivid, often subjective experiences that occur during the dying process. Even though the patient and family experiences of ELDVs are well documented, there is limited knowledge regarding the perspectives, preparedness, and perceived needs of health care professionals. ELDVs also remain insufficiently addressed in clinical care. Objective: To describe how frequently clinicians encounter ELDVs, perceived preparedness/training, and approaches to clinician and family education and communication. Methods: We conducted a survey to explore health care professional’s perspectives and experiences surrounding ELDVs. The Checklist for Reporting Results of internet E-Surveys was followed. Our survey included 30 items across 7 sections. Professionals that take care of patients with serious or terminal illness were eligible for the study. We utilized a structured multimodal dissemination to achieve maximum diversity in participants. Results: Briefly, 247 participants were eligible for analysis. Frequent encounters for ELDVs were reported by participants. Participants perceived positive effects on patients more frequently than negative effects (W = 446.0, p < 0.001, r = 0.64). Clinical challenges were rated differently across categories (χ ² = 160.97, p < 0.001, Kendall’s W = 0.13). The most commonly endorsed clinical challenges were lack of institutional protocols and lack of standardized diagnostic criteria, both rated significantly higher than all other challenges (Bonferroni-corrected Wilcoxon tests: All p < 0.001). Participants endorsed multidisciplinary involvement and formal policy implementation. Conclusion: ELDVs are common, but clinicians feel underprepared to respond to them. There is a need for structured training and institutional protocols. Future studies should include patients and their families and analyze how their experiences are shaped by physician responses.

Background: Individuals showing concurrent and rapid declines in cognitive and motor performance (i.e., dual decliners) are at increased risk of faster progression to dementia. Still, the role of Alzheimer's disease (AD) pathology in motor/cognitive joint trajectories remains poorly understood. Objectives: To test the association between blood AD biomarkers and different patterns of decline of cognitive and motor functions in an aging, community‐dwelling population. Methods: We included 1660 dementia‐free participants from the Swedish National Study on Aging and Care in Kungsholmen. Cognitive and motor functions were assessed over 15 years using the Mini‐Mental State Examination and gait speed. Based on individual decline rates derived from linear mixed models, participants were classified as slow/non‐decliners, fast motor decliners, fast cognitive decliners, or dual decliners. Baseline plasma concentrations of AD biomarkers (amyloid‐β [Aβ] 42/40 ratio, phosphorylated tau 217 [p‐tau217], phosphorylated tau 181 [p‐tau181], total tau, neurofilament light chain [NfL], and glial fibrillary acidic protein [GFAP]) were quantified using single‐molecule array assays. Associations between standardized biomarker levels and decline patterns were tested using multinomial logistic regression. Results: Higher plasma levels of p‐tau217 (odds ratio [OR] 2.69, 95% confidence interval [CI] 2.34–3.09), p‐tau181 (OR 1.78, 95% CI 1.60–1.98), and NfL (OR 1.47, 95% CI 1.34–1.61) were most strongly associated with dual decline, compared with slow/no decline. Although a lower Aβ42/40 ratio and higher GFAP levels were mainly linked to isolated cognitive, p‐tau217 alone was associated with future isolated motor decline. Conclusions: In this population‐based study, distinct AD blood biomarkers were associated with different patterns of cognitive and motor decline. Whether these represent separate pathways or a clinical continuum, further research is needed to clarify underlying mechanisms and inform clinical applications.

Frailty is increasingly recognized as a major determinant of surgical risk in older adults; however, its prognostic significance in the context of elective neurosurgery remains unclear. This study investigated the prevalence of frailty, the concordance between three validated frailty instruments, and their association with postoperative complications. A prospective cohort study was conducted at a tertiary neurosurgical center from November 2021 to November 2024. Patients aged ≥ 65 years undergoing elective cranial or spinal surgery were included. Preoperative frailty was assessed using the Clinical Frailty Scale (CFS), the Comprehensive Geriatric Assessment Frailty Index (CGA-FI), and the Fried’s Frailty Phenotype (FFP) criteria. Postoperative complications—including infectious, cardiovascular, neurological, haemorrhagic events, delirium, and in-hospital death—were systematically recorded. Associations with frailty were examined using multivariable logistic regression adjusted for covariates. Among 181 patients (mean age, 74.1 [SD] 6.1 years), frailty prevalence ranged from 23.8% (CGA-FI) to 44.2% (FFP). Agreement between instruments was variable, with substantial concordance between CFS and CGA-FI (κ = 0.65) and only moderate concordance with FFP. Postoperative complications occurred in 47 (25.9%) patients. Frailty defined by CFS (adjusted odds ratio [aOR], 2.73; 95% CI, 1.05–7.42) and CGA-FI (aOR, 3.78; 95% CI, 1.34–11.1) was independently associated with increased risk of complications. In conclusion, frailty as assessed by the CFS and CGA-FI, is a strong determinant of postoperative risk in older adults undergoing elective neurosurgery. Incorporating frailty assessment into routine neurosurgical pathways may improve perioperative risk stratification and guide clinical decision-making.

Aging is accompanied by the progressive accumulation of biological deficits, which increases susceptibility to developing multiple chronic diseases (that is, multimorbidity). The biological underpinnings of multimorbidity remain poorly understood. Here we analyzed 54 blood biomarkers reflecting inflammatory, vascular, metabolic and neurodegenerative processes in 2,247 individuals aged 60 and over from the Swedish National Study on Aging and Care in Kungsholmen. Multimorbidity was assessed using three measures: baseline total disease count, baseline multimorbidity patterns identified through latent class analysis and 15-year rate of disease accumulation. Associations between baseline biomarkers and multimorbidity measures were examined using least absolute shrinkage and selection operator regression. Growth differentiation factor 15, hemoglobin A1c, cystatin C, leptin and insulin were consistently and positively associated with all multimorbidity measures. Additional biomarkers demonstrated specific associations with distinct multimorbidity patterns. Moreover, faster disease accumulation was directly associated with gamma-glutamyl transferase and inversely with albumin. Longitudinal results were externally validated in 522 participants from the Baltimore Longitudinal Study of Aging, with comparable predictive accuracy. Our findings suggest that multiple biological processes contribute to multimorbidity through shared and distinct mechanisms. Metabolic disturbances emerged as a key driver of multimorbidity. If confirmed, these processes could represent targets for interventions to mitigate disease accumulation.

Hs-TnT: high sensitivity Troponin T; STEMI: ST-elevation myocardial infarction.

Purpose: To explore the prevalence, overall and in different clinical settings, and interconnectedness, of delirium, dementia, and frailty clinical pathways across Europe. Methods: An online anonymous survey was distributed via the mailing list of the European Geriatric Medicine Society (EuGMS), national member groups and the authors’ professional networks, targeting geriatricians, or trainees in their final 2 years of specialist geriatric training, working in a hospital, rehabilitation, post-acute care or residential setting in a European country. Quantitative data were summarized using descriptive statistics and frequency distributions. Inductive content analysis was used to interpret open-text questions. Results: The 240 respondents were predominantly female (63%), with a 6:1 consultant to trainee ratio and marked underrepresentation of Eastern Europe. Integrated care pathways (current or in-development) for delirium, dementia, or frailty are reported in 48–78% of settings. Dementia and delirium pathways are common except in radiology, neurosurgery, and operating/recovery settings. Frailty pathways are less common overall, and specific frailty staff are less common than dementia or delirium staff. Dementia pathways commonly incorporate delirium screening (76%) and prevention (73%), but less commonly frailty screening (61%). Similarly, delirium pathways often provide guidance on formal dementia diagnosis (62%) but less than half incorporate frailty screening/assessment (46%). Notably, only 19% of delirium pathways differentiate between managing delirium and delirium-superimposed-on-dementia (DSD). Frailty pathways frequently incorporate cognitive assessment (81%) and delirium screening/assessment (75%), but only 57% incorporate delirium prevention. Conclusion: Dementia and delirium pathways are more common and more integrated and inclusive of each other than frailty pathways. More unified approaches could maximize the value of staff time, reduce duplications, and avoid a siloed approach to the care of older people.