An algorithm for the early diagnosis and correct approach to dementia management: results of a multiprofessional team.

BACKGROUNG: The early identification of cognitive disorder is a primary scope, because it could reduce the rate of severe cognitive impairment and thus contribute to reduce healthcare costs in the next future. AIMS: The present paper aimed to build a virtuous diagnostic path of cognitive impairment, highlighting all the professionalism that can serve this purpose. METHODS: The Delphi method was used by the experts, who reviewed the information available during each meeting related to the following topics: early diagnosis of cognitive impairment, definition of Mild Cognitive Impairment, unmet needs in post-stroke patients, critical decision-making nodes in complex patients, risk factors, neuropsychological, imaging diagnosis, blood tests, the criteria for differential diagnosis and the possible treatments. RESULTS: The discussion panels analyzed and discussed the available evidences on these topics and the related items. At each meeting, the activities aimed at the creation of a diagnostic-welfare flow chart derived from the proposal of the board and the suggestions of the respondents. Subsequently, the conclusions of each panel were written, and the study group reviewed them until a global consensus was reached. Once this process was completed, the preparation of the final document was carried out. CONCLUSIONS: Eventually, we built an algorithm for the early diagnosis and treatment, the risk factors, with the possible differences among the different kinds of dementia.

The doll therapy as a first line treatment for behavioral and psychologic symptoms of dementia in nursing homes residents: a randomized, controlled study.

BACKGROUND: Patients living with dementia are severely affected by the development of behavioral and psychologic symptoms (BPSD) which represent a burden for patients and caregivers. The use of psychotropic drugs in the control of BPSD is widely diffused, however the use of a first line non-pharmacologic approach is highly recommended. Here we evaluate the effect of doll therapy (DT) in the management of BPSD, on the reduction of caregiver burden and delirium incidence in nursing home residents by a randomized controlled trial. METHODS: We enrolled fifty-two nursing homes residents living with dementia and BPSD. Subjects were randomized to DT (26) or standard treatment (ST, 26), we measured BPSD, caregiver burden and delirium with standard clinical scales at baseline, after 45 and 90 days. In order to evaluate the presence of BPSD we used Neuropsychiatric Inventory (NPI) scale and the A.Di.CO scale, the caregiver burden was measured by the Greutzner scale and delirium by the Confusion Assessment Method (CAM) scale. RESULTS: DT was more effective in reducing agitation and aggressiveness as respect to ST. Moreover DT globally reduced the presence of BPSD as dysphoria, wandering and apathy. We observed a significant reduction of the professional caregiver burden and the incidence of delirium was significantly reduced in subjects treated with DT. CONCLUSIONS: We show that DT is more effective that ST in the control of BSPD in patients affected by moderate to severe dementia. Moreover we suggest that DT may effective in reducing the incidence of delirium. TRIAL REGISTRATION: Retrospectively registered in ClinicalTrials.gov the 10th June 2, 2021 trial registration number NCT04920591.

The Pupil Diameter as a Possible Indicator of Neurodegenerative Diseases and Response to Acetylcholinesterase Inhibitors Therapy: In-Depth Measurements Following Topical Administration of Tropicamide and Pilocarpine.

BACKGROUND: The aim of this study is to assess whether pupillary modifications following ocular anticholinergic and cholinergic drugs can identify subjects with neurodegenerative diseases from early stages. METHODS: 51 subjects were divided into 3 groups, according to different neurodegenerative diseases, and compared with a control group of 10 patients. Pupil diameter has been measured at different times after topical administration of tropicamide 0.01% in the right eye. Then, topical administration of pilocarpine 0.06% has been performed, followed by pupillary constriction measurement. Pupillary response rates were stratified according to acetylcholinesterase inhibitors intake. RESULTS: Observed mydriasis and pupillary constriction was similar in all study groups at all evaluation times. Patients without acetylcholinesterase inhibitors intake presented greater mydriasis. CONCLUSIONS: Although it was not possible to observe significant differences among groups in terms of pupillary response, the analysis of pupillary features may become an useful tool to detect efficacy of acetylcholinesterase inhibitors.

The scent of emotions: A systematic review of human intra- and interspecific chemical communication of emotions.

OBJECTIVE: The sense of olfaction has been considered of minor importance in human communication. In recent years, evidence has emerged that humans might be influenced by unconscious messages sent through chemosignals in body odors. Data concerning the ability of humans to recognize fear, maybe related to the evolutionary role of these emotions in the fight-or-flight reactions, are well known. METHODS: To further understand the role of emotional chemosignals in mediating communication in humans and its influence on animal behaviors, we conducted a systematic literature review. RESULTS: Chemosignals derived from axillary odors collected under a variety of emotional stimuli and sad tears in humans affect receivers' social interactions, danger detection and risk-taking behavior, social aspects of eating, and performance under stressing conditions. In addition, beyond the fight-or-flight response, even the body odors of happiness can be perceived by others. Furthermore, human chemosignals can influence behaviors and stressful responses in animals, particularly dogs and horses, which may partially explain their special relationship with humans. CONCLUSION: Our review highlights the importance of chemosignaling in human intra- and interspecific interactions and suggests the need for further investigations, both in physiological conditions and in patients with psychiatric or neurodegenerative disorders.

Hyponatremia, Hypokalemia, and Fragility Fractures in Old Patients: More than an Association?

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.

From mitochondria to healthy aging: The role of branched-chain amino acids treatment: MATeR a randomized study.

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 open-label randomized trial and administered a particular 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 s Chair Sit to Stand (30-s CST) test and the 4 m 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.

Similar neurocognitive patterns in patients treated with lenalidomide: chemobrain effect?

Purpose: o report and describe cognitive impairments during lenalidomide treatment in three patients. Despite the relevant clinical impact of chemotherapy-related cognitive deficit (known as "chemobrain effect"), very few data are available in the literature. Methods: We present three subjects who developed cognitive impairment during treatment with lenalidomide. Their neuropsychological assessment was evaluated in order to better define the cognitive areas involved. For each patient medical history, drug therapy, physical examination and other instrumental tests (brain CT scan and/or MRI scan, FDG-PET and electroencephalography) were collected. Results: In all patients, we observed an homogeneous neuropsychological pattern characterized by long-term verbal and visuospatial memory deficits, and decline in attentional and executive functions. Conclusions: Lenalidomide treatments can determine severe cognitive impairments especially in elderly patients. Our data suggest the need for a careful evaluation of cognitive decline risk before and after drug administration. However, larger studies are required to confirm our findings.

Malnutrition in an elderly demented population living at home.

Malnutrition is a frequent complication for elderly demented patients even if they live at their own home with the assistance of a caregiver. The present study evaluates nutritional characteristics of a population of 130 non-institutionalized demented patients. The results show that the mini nutritional assessment (MNA) total score is inversely related with the neuro-psychiatric inventory (NPI) score and that the level of cognitive impairment is related with the nutritional status: patients with mild cognitive impairment (MCI) showed a mean MNA score higher than patients affected by Alzheimer's disease (AD) or vascular dementia (VaD). Moreover, patients depressed, with hallucinations or with behavioral disturbs are more exposed to underfeeding than only cognitively impaired subjects. In conclusion, an appropriated evaluation of nutritional status could prevent and treat nutrition-related problems even in the elderly demented patients living at home.

Stress in professional care-givers working with patients with dementia: a hypothesis-generating study.

BACKGROUND AND AIMS: Caregiving can be extremely stressful, especially when patients' ability to communicate is impaired. While the stress undergone by relatives assisting their loved ones has been widely investigated, fewer data can be found about the stress in healthcare professionals. The aim of this study is to evaluate whether a specific training course could be related to a reduction in the levels of stress of professional care-givers working with patients suffering from dementia. METHODS: Work-related levels of stress of study participants were evaluated with the Staff Stress Measure Dementia Care Scale, at baseline and four months after completion of an eight-month training course. RESULTS: We found no significant correlation between care-givers' age, gender, marital status, years of employment or perceived economic status, and their stress levels at baseline. Patients' characteristics were not related with care-givers' stress at baseline. The mean level of stress was significantly reduced (34.64±4.15 vs 26.64±3.82, p<0.001) between baseline and the study endpoint. CONCLUSIONS: Increased knowledge of management of patients affected by dementia could help professional care-givers to reduce their work-related stress. Our results add to the evidence of the benefit of personnel support in reducing levels of stress at work.

Geriatric ward hospitalization reduced incidence delirium among older medical inpatients.

OBJECTIVES: Most strategies for delirium prevention in older hospitalized patients are common good clinical geriatric care. We investigated whether acute geriatric ward (AGW) hospitalization, compared with acute general medical ward (AGMW) hospitalization,is associated with reduced incident delirium in older medical inpatients. DESIGN: prospective observational study. SETTING: a tertiary care, university hospital in Torino. PARTICIPANTS: consecutive medical patients 70 years or older admitted from the emergency department to an AGW and to an AGMW were included. MEASUREMENTS: Baseline measures included demography, functional and psychocognitive status, comorbidity, physiological and clinical severity of acute illness. Incident delirium was evaluated by qualified psychiatrists according to the Confusion Assessment Method and the Delirium Rating Scale. RESULTS: Delirium occurred in 8 of 121 patients admitted to AGW (6.6%) and in 20 of 131 patients admitted to AGMW (15.2%). After adjustment for significant differences in baseline covariates between groups, AGW hospitalization remained independently associated with less incident delirium (relative risk 0.90, 95% confidence interval: 0.024-0.331, p <0.001). In a multivariable logistic model with delirium incidence as independent variable, AGW hospitalization was independently associated with lower delirium incidence (relative risk 0.039, 95% confidence interval: 0.007-0.214, p <0.001), whereas greater cognitive impairment (p <0.001), higher Acute Physiology and Chronic Health Evaluation II score (p 0.001) and recent stressful events (p <0.001) were associated with increased delirium incidence. CONCLUSION: AGW hospitalization is associated with less incident delirium among older medical inpatients. Despite inherent limitations of observational studies, these hypothesis-generating findings add to previous evidence of potential benefit in delirium prevention from geriatric consultation in several hospital settings.

Efficacy of oxycodone/acetaminophen and codeine/acetaminophen vs. conventional therapy in elderly women with persistent, moderate to severe osteoarthritis-related pain.

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.

White-coat effect among older patients with suspected cognitive impairment: prevalence and clinical implications.

OBJECTIVES: To evaluate the prevalence of white-coat effect (WCE), and its association with individual anxiety and insight of disease, among older patients evaluated for suspected cognitive impairment. METHODS: This prospective cohort study, conducted in an Alzheimer Evaluation Unit, involved patients aged 55 years or older with suspected cognitive impairment. WCE was defined as a difference of at least 20 mmHg in systolic or 10 mmHg in diastolic blood pressure (BP) measured either by a physician during the visit or by a nurse (before and after the visit), compared with home self-blood pressure measurement (SBPM). Severity of cognitive impairment was evaluated through the Mini-Mental State Examination (MMSE); the Clinical Insight Rating Scale (CIR) and the Guidelines for the Rating for Awareness Deficits (GRAD) were used to evaluate the subject's insight; anxiety disorder was evaluated using the seven-question Generalized Anxiety Disorder scale (GAD-7). RESULTS: Among 273 subjects, prevalence of WCE was 52%, 32.6% and 30.4%, according to physician and nurse BP measurements, respectively (p = 0.000). Prevalence of WCE did not differ between patients diagnosed with and without dementia, but was higher among patients with than in those without anxiety disorder (70.7% vs 38.2%, p = 0.000). Positive relations were observed between severity of anxiety and insight of disease, which were both inversely related with severity of cognitive impairment. CONCLUSIONS: WCE is extremely common and is correlated to individual anxiety and insight of disease among older outpatients with suspected cognitive impairment; overestimation of hypertension severity might lead to unnecessary drug treatment and greater health costs in this setting.

Dehydroepiandrosterone sulfate (DHEA-S) and Alzheimer's dementia in older subjects.

OBJECTIVES AND METHODS: We investigated the association of serum dehydroepiandrosterone sulfate (DHEA-S) levels with dementia of Alzheimer's type (DAT) and impairment in selected cognitive domains (memory, language, attention and working memory) in 158 patients (75.5+/-6.7 years, 46 men) with first-diagnosed probable DAT and in 158 age- and sex-matched controls. As secondary goal, we evaluated whether DHEA-S baseline levels were associated with cumulative 6-year mortality. RESULTS: A negative correlation between DHEA-S levels and age was observed (R=-0.25, p<0.001). Age-stratified analysis did not show significant differences of DHEA-S levels between DAT patients and controls. No significant association was found between DHEA-S levels and impairment in selected cognitive domains. Cox regression analysis showed that baseline DHEA-S levels were not associated with cumulative 6-year mortality. CONCLUSIONS: In a sample of newly-diagnosed DAT patients, we did not find significant association between presence of DAT or impairment in cognitive domains and DHEA-S levels; baseline DHEA-S levels are not associated with cumulative mortality in patients and controls.

Risk of cognitive decline in older patients after carotid endarterectomy: an observational study.

OBJECTIVES: To determine whether patients undergoing carotid endarterectomy (CE) for symptomatic left internal carotid artery (LICA) stenosis have greater risk of cognitive decline than patients with asymptomatic LICA disease or right internal carotid artery (RICA) disease. DESIGN: Observational. SETTING: Vascular surgery day hospital. PARTICIPANTS: The analysis included 103 patients (mean age 72.6+/-7.0, 73 men), of whom 50 had LICA disease (29 symptomatic). MEASUREMENTS: Cognitive function was evaluated (age- and education-adjusted Mini-Mental State Examination (MMSE), and Clock tests (CLOX1 and 2)) at baseline and at the end of the study period (average follow-up+/-standard deviation 44.4+/-14.3 months) in a sample of patients aged 65 and older, free from cognitive impairment, consecutively undergoing CE. RESULTS: At the end of the study period, MMSE, CLOX1, and CLOX2 scores were significantly lower in patients with symptomatic LICA disease (P<.001, P<.001, and P=.002, respectively) and not in the other groups of patients. Patients with symptomatic LICA disease had greater risk of cognitive decline than other individuals according to MMSE score (F=5.18, P=.002) or CLOX1 and 2 scores (F=5.66, P=.001, and F=4.33, P=.006, respectively). CONCLUSION: 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.

Cognitive function after carotid endarterectomy: greater risk of decline in symptomatic patients with left internal carotid artery disease.

BACKGROUND: The risk of cognitive decline in patients undergoing carotid endarterectomy (CE) for left internal carotid artery (ICA) (LICA) disease before or after the occurrence of ischemic symptoms has not been fully elucidated. We evaluated whether patients undergoing CE for symptomatic LICA stenosis have greater risk of cognitive decline than patients with asymptomatic LICA disease or right ICA disease. METHODS: In a series of patients aged 65 years and older, consecutively undergoing CE and free from cognitive impairment, cognitive function was evaluated through the age- and education-adjusted Mini Mental State Examination and the Clock Drawing Task at baseline and at the end of the study period (average follow-up: 44.4 +/- 14.3 months). RESULTS: The analysis included 103 patients (mean age 72.6 +/- 7.0 years; 73 men), of whom 50 had LICA disease (29 symptomatic). At the end of the study period, Mini Mental State Examination score was reduced in patients with symptomatic LICA disease (P < .001) but not in other patients, whereas the Clock Drawing Task score was reduced in both patients with LICA and right ICA. Patients with symptomatic LICA disease had greater risk of cognitive decline than other individuals, either measured by the Mini Mental State Examination score (F = 5.18, P = .002) or by the Clock Drawing Task score (F = 9.42, P = .001). CONCLUSIONS: Patients undergoing CE for symptomatic LICA disease appear to be at increased risk of cognitive decline than other individuals. Further studies are needed to confirm these findings and to evaluate whether LICA endarterectomy before occurrence of cerebrovascular ischemic symptoms may provide additive benefit in the prevention of cognitive decline.

Home hospitalization service for acute uncomplicated first ischemic stroke in elderly patients: a randomized trial.

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.

Predictive factors of in-hospital mortality in older patients admitted to a medical intensive care unit.

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.