Psychiatric comorbidity in the frail patient.

The psychopathological syndromes associated with the organic disease in the frail patient are put in the focus of our studies. In the frail patient, mood disorders show a multifacet appearance often associated to the invalidating pathologies or determined by the interaction between the diseases and the individual personality traits. A psychotic break can worsen the evolution of the clinical status. In the clinical practice with the frail elderly, the diagnostic and therapeutic phases change to some extent. The psychiatric diagnosis based upon the DSM-IV-TR shall include a multiaxial approach, with the general medical conditions coded on axis III. The therapeutic planning must be based on rules taken from the field of sciences of complexity; in the field of complexity, the evolution of the clinical status is not expectable and the points of discontinuity are the rule. The difficulties to reach a "secure base" makes the therapeutic dynamics be attracted from areas of stability in the mid of chaos, named "chaotic attractors".

Nutritional status and evolution of pressure sores in geriatric patients.

UNLABELLED: The prevalence of pressure sores (PS) ranges from 1 to 18% of in-patients and from 3 to 28% of those admitted to long-term settings. The aim of our study was to verify, a posteriori, how nutritional status influenced the evolution of PS in a population of elderly subjects hospitalised in a long-term care setting. MATERIALS AND METHODS: The charts of 125 patients with ulcerative or necrotic pressure ulcers were evaluated retrospectively. For each subject we took note of: PS characteristics (stage, ulcer surface, evolution), clinical characteristics (comorbidity, adverse clinical events, cognitive, functional and nutritional status). RESULTS: In 58 patients (46.4%) there was overall healing of the lesions while in 39 patients (31.2%) we had however an "improvement" of PS. The course of PS was not significantly influenced by the patient's physiological characteristics, by cognitive status or by initial characteristics of PS. Instead, we noticed a significant difference in the course of PS as a function of the level of autonomy and clinical status. The course of PS, and in particular the Healing Index, were influenced by the Nutritional Status and, above all, by its course during the treatment period. CONCLUSIONS: The development of PS is multifactorial. Whereas, it is clear that factors other than nutrition influence the risk of developing PS, an important role for nutrition in the development and resolution of PS is suggested. Our data certainly confirm the "Quality indicators for prevention and management of pressure ulcers in vulnerable elders", especially were they say "if a vulnerable elder is identified as at risk for pressure ulcer development and has malnutrition, then nutritional intervention or dietary consultation should be instituted because poor diet, particularly low dietary protein intake, is an independent predictor of pressure ulcer development".

Administering the "AHSP Questionnaire" (appetite, hunger, sensory perception) in a geriatric rehabilitation care.

BACKGROUND: Frail elderly people, living in nursing homes, usually show a malnutrition state caused by an increased need of energy or an inadequate food intake. Among the causes leading to reduction of food intake in elderly people and consequently to malnutrition, is the loss of appetite, often marker of depression and alterations of taste and smell perception. OBJECTIVE: The aim of this research is to verify the application of the AHSP Questionnaire and relate its score to nutritional state of a frail elderly population hospitalized in a geriatric rehabilitation care. SETTING AND SUBJECTS: All patients of the "3rd Rehabilitation Department" of the Istituto Geriatrico "Villa delle Querce" Nemi (Rome-Italy). METHODS: Informations, number and type of medical conditions, prescribed drugs, other parameters that can affect taste, smell, hunger and nutritional status, mood, cognitive and nutritional status have been collected from the clinical folders. To assess appetite, hunger smell and taste perception had been submitted the AHSP Questionnaire. RESULTS: The AHSP Questionnaire had been administered only to 44 of the 103 patients present at the survey because of the high prevalence of cognitive impairment. AHSP score is lower in presence of malnutrition assessed with MNA (Mini Nutritional Assessment). MNA, expressed as proportional score, seems to present a clear correlation with AHSP's (r=0.59; p=0.000). CONCLUSION: The results achieved show the scarce adaptability of the AHSP Questionnaire to frail elderly people living in geriatric rehabilitation care. MNA is at the moment the most reliable tool to single out dietary deficiency on geriatrics population.

MNA predictive value in the follow-up of geriatric patients.

OBJECTIVE: The aim of this study is to verify, in a sample of elderly subjects admitted to long-term care, the impact of malnutrition, according to the Mini Nutritional Assessment (MNA), on mortality and on the occurrence of Adverse Clinical Events in a 3-12 months follow-up study. SUBJECTS: The survey included all patients admitted to a geriatric hospital--"Villa delle Querce", Nemi (Rome, Italy)--between January 1997 and April 2000, whose nutritional status we were able to monitor for over 3 months. The study comprised 167 elderly subjects, of which 125 women (74.9%) aged 83.3 8 years (60-95 years), and 42 men (25.1%) aged 79.6 9 years with an average follow-up period of 7.5 months. METHODS: Upon admission and at every check we evaluated each subject's cognitive functions, functional status, co-morbidity, frailty, nutritional status (anthropometric and biochemical indices; MNA). During the follow-up we recorded Adverse Clinical Events. We calculated the predictive value of MNA, we correlated variations in MNA scores with variations of nutritional parameters. RESULTS: MNA's predictive ability both upon admission and upon discharge was found to be excellent. The MNA score was found to be correlated-although not to a very high degree-with variations nutritional parameters. Even more than malnutrition, a low MNA score was found to be predictive of a greater incidence of Adverse Clinical Events during hospitalisation and of higher mortality.

[The quality of a restaurant service at a geriatric rehabilitation facility]. / Valutazione oggettiva e soggettiva della qualità di un Servizio di Ristorazione collettiva in una Struttura di Riabilitazione Geriatrica.

The aim of our study was to measure the quality of a restaurant service of a geriatric rehabilitation and long-term setting as it is perceived from patients compared with an objective measure of the quality. We have also verified the weight of the restaurant service on the whole quality of the hospital. Our data showed some problems in the organisation of the service, a substantially negative judgment from patients, the necessity to integrate subjective judgments with objective evaluations. The data confirmed also the importance that patients give to taste and variability of food and to the way in which it is presented. The results we obtained suggested an audit of the organisation of the restaurant service. The outcome of the proposed changes will be followed up and bring, eventually, to further arrangements.

A "proportional and objective score" for the mini nutritional assessment in long-term geriatric care.

BACKGROUND: In a previous study we tested the predictive value of the Mini Nutritional Assessment (MNA) in an Italian population of frail elderly in long-term hospital care. The results of our study confirmed the MNA's excellent overall predictive value and sensitivity. Unfortunately we had a large number of false positive judgments, hence our study's low specificity, which we think was caused by two factors: 1. in most cases it was impossible to conduct a reliable subjective assessment of the patients' nutritional and health status. 2. most patients failed to respond to some of the MNA questions, which as a consequence received a "0" score. The result was an artificially low global MNA score even in well-nourished patients. OBJECTIVE AND DESIGN: We tried to neutralize the effects of the defective answers by modifying the total score and the cut-off points of the test. Thus, we: 1. replaced the subjective assessment of health and nutritional status with an objective evaluation; 2. replaced the total score of MNA with the ratio of this value with the maximum of points that each subject can obtain without including the items for which we could not have a response. Similarly, the cut-off points (17 and 24) were replaced with the ratio of these values with the maximum of points obtainable by a complete MNA (30). Patients are classified as "malnourished" below 0.56, "at risk of malnutrition" between 0.56 and 0.79, and "well-nourished" from 0.8 up. RESULTS: This way, the overall predictive value of MNA is increased from 80.3 to 85.4% and the specificity from 12.8 to 25%, whereas the sensitivity increase is modest (from 98 to 98.1%).

Prediction of stature in the Italian elderly.

Adequate quantification of weight and stature is essential in order to determine levels of nutritional support and to monitor the effects of nutritional intervention. Traditional anthropometric techniques are difficult to apply in elderly or handicapped patients chair or bed-bound. The purpose of the present study is to elaborate regression equations for the estimation of stature in the italian elderly population from other anthropometric measures that can be more easily determined. We have found a single model valid for both sexes (in which the value of the variable "sex" equals 0 if woman and 1 if man) to predict stature in italian elderly: Stature = 94.87 + 1.58 knee-height - 0.23 age + 4.8 sex. Cross validation on a control sample of 30 males and 54 females yielded pure errors of 3.1 cm for men and 2.74 cm for women.

DNA polymorphisms of apolipoprotein B and angiotensin I-converting enzyme genes and relationships with lipid levels in Italian patients with vascular dementia or Alzheimer's disease.

The distribution of three DNA polymorphisms (XbaI, EcoRI, and I/D) of the apolipoprotein B (APOB) gene, and of the I/D polymorphism of the angiotensin I-converting enzyme (ACE) gene was investigated in 53 patients with vascular dementia, in 80 patients with late-onset sporadic Alzheimer's disease, and in 153 age-matched control subjects. Furthermore, plasma total cholesterol, LDL cholesterol, HDL cholesterol, and triglycerides were measured in the three groups and the involvement of the genetic variation at APOB locus on lipid levels was determined. Major findings of this work are (1) no genotype or allele of the polymorphisms examined here seemed to be associated with vascular dementia or with Alzheimer's disease, (2) total cholesterol and LDL cholesterol levels were lower in Alzheimer's disease patients than in vascular dementia patients and in elderly controls, and (3) the dementia patients with APOB EcoRI R+R- genotype had higher total cholesterol and LDL cholesterol levels than R+R+ homozygotes.

Body weight estimation in the Italian elderly.

We have developed two different equations, for each sex of the elderly italian population to predict weight from selected measures of recumbent anthropometry, using data of 172 females (72.8 +/- 8 years old) and 113 males (73.4 +/- 8 years old). The independent variables for both sexes were knee stature. subscapular skinfold, arm and calf circumferences. Cross validation was conducted on a free-living sample of 54 females and 30 males. The recommended equations have a 95% probability of predicting the weight of an elderly man or woman to be within plus or minus 4.9 or 6.1 Kg respectively.

Apolipoprotein E (APOE) allele frequencies in late-onset sporadic Alzheimer's disease (AD), mixed dementia and vascular dementia: lack of association of epsilon 4 allele with AD in Italian octogenarian patients.

The Apolipoprotein E (APOE) epsilon 4 allele has been found to be strongly associated with Alzheimer's disease (AD) in most studies conducted up to now, though not all investigators have established a similar association with other forms of dementia, like vascular dementia. Our study examined the APOE polymorphism in a sample of 149 dementia patients, of which there were 80 with probable sporadic late-onset AD, 16 with a mixed form of dementia (MD), and 53 with vascular dementia (VD). An elderly control sample was composed of 126 subjects. The data obtained on the whole AD sample did not confirm the association already reported with APOE epsilon 4. A difference did emerge when the subjects were subdivided on the basis of age at the examination. AD patients aged < or = 80 years significantly differed from the correspondent elderly controls, while no difference was observed between the patients aged 81 years or older and controls. This pattern could be due to a previous disadvantageous effect of the epsilon 4 allele on the subjects bearing it. A substantially similar pattern was observed in the few MD patients, while no differences were found in the two VD subgroups. The odds ratio (OR) for AD associated with at least one epsilon 4 allele was significant and equal to 3.3 (95% CI = 1.2-9.1) for the < or = 80 age class, while it was not significant and equal to 1.1 (95% CI = 0.4-2.8) for the > 80 age class. Our data indicate that in AD patients aged less than 81 years, epsilon 4 is clearly associated with AD and that it can be considered a risk factor for AD chiefly before this age.