[The dependence medical index (DMI): validation and comparison with the activity daily living and the instrumental activity daily living]. / L'indice medico di non autosufficienza: validazione e comparazione con le scale ADL e IADL.

AIM: The aim of this study was the validation of the dependence medical index (DMI), a disability medical assessment tool in the elderly. METHODS: Study sample included 1054 subjects aged 65 and over, consecutively admitted to the University Department of Geriatric Medicine of Turin, Italy. A total of 356 of these subjects was classified as dependent to activity of daily living (ADL) and instrumental activity of daily living (IADL) scales. Some conditions causing medical dependence were detected, such as strength and/or motility impairment, incontinence, pressure sores, disturbances in speech and communication, decline in sight and/or hearing, terminal illness (death expected within 6 months), need for multiple and complex therapies, episodic disorientation, dizziness with tendency to fall, use of the wheel-chair. The relationship between dependence and the DMI was studied by discriminant analysis. A scale was created using the discriminant scores of each 15 medical indications for disability. RESULTS: The discriminant model of DMI was validated by cross-validation statistical method: its application permitted to classify correctly 73.1% of the sample. The DMI permitted to classify the dependent subjects in variable percentages: from 67% (DMI score > or =1) to 90% (DMI score > or =7). The best ratio between specificity and sensibility was for score 4 to DMI. CONCLUSION: The conclusion is drawn that DMI can be used to detect and evaluate the disability for medical reasons in elderly people.

Home care for demented subjects: new models of care and home-care allowance.

This study on home care for demented patients is one of the finalized research projects sponsored by the Ministry of Health. The teams involved are: the Home Hospitalization Service (HHS) of S. Giovanni Battista Hospital of Torino, the "Azienda Sanitaria Locale n 20" (ASL 20) of Alessandria and Tortona and the "Presidio Ospedaliero Riabilitativo Fatebenefratelli" of San Maurizio Canavese (Torino). Aim of the study is to assess the feasibility and usefulness of taking care of elderly demented patients at home and to improve the quality of life of patients and their relatives, involving training experiences and economic help. The Geriatric Department of San Giovanni Battista Hospital started a randomized controlled study on 109 severely demented subjects admitted to the emergency room of the hospital. Fifty-three patients were transferred to the traditional geriatric ward and 56 to the HHS. The team of ASL 20 of Alessandria and Tortona selected and evaluated 45 elderly demented patients living at home. These subjects, stratified for their cognitive and functional impairment, were randomly allocated to two different groups: a group receiving an economic help for one year and a control group. In the first setting of research the degree of dementia was severe, mini mental state examination (MMSE) score was 10.0 +/- 5.2 for patients at home, and 10.5 +/- 6 for the second group. The majority of patients followed at home (78.6 %) were discharged, while only 47.2 % of the in-patients returned home (p < 0.001). Seventeen out of 53 patients (32.1 %) admitted to the traditional ward and only two of home-hospitalization patients had to be sent to nursing home (p <0.001). The 45 subjects evaluated by the team of ASL 20 were divided into two groups.Twenty-four subjects were allocated to receive a home care allowance. Their functional status was impaired. Their MMSE score was 12.6 +/- 5.4 and clinical dementia rating scale(CDR) score 2.7 +/- 0.9. A control group of 21 subjects (17 women and 4 men) showed similar characteristics as the previously described group.

A randomized controlled trial of a home hospital intervention for frail elderly demented patients: behavioral disturbances and caregiver's stress.

A Geriatric Home Hospitalization Service (GHHS) has been operating in Torino at S. Giovanni Battista Hospital since 1985. GHHS allows us to perform diagnostic and therapeutic interventions, which are usually made in hospital, also at home. GHHS team includes geriatricians, nurses, physiotherapists, social workers and counselors. Between February 1999 and April 2002, the GHH Service conducted a randomized controlled trial on 109 elderly, demented patients requiring admission to the Hospital Emergency Department (ED)for acute illnesses. Objective of the study was to identify the benefits of the care in a GHHScompared to a general medical ward (GMW) in reducing behavioral disturbances in elderly patients with advanced dementia and in lowering caregiver's stress. Patients were randomly assigned to GHHS (56 patients) or to GMW (53 patients). Both groups were examined using the same protocol and were evaluated on admission and on discharge. All patients had a severe form of dementia as shown by the clinical dementia rating (CDR) scale mean value (3.7 +/- 0.9) with an important functional impairment and a relevant degree of comorbidity.The main reasons for hospitalization were infections, cerebrovascular accidents and malnutrition. Mortality of total sample was 19.3 %, without significant differences in the two settings of care. On discharge, in GHHS patients there was a significant reduction of behavioral disturbances. The use of anti-psychotic drugs was significantly lower in GHHS patients compared to the GMW group (p < 0.001). The stress of caregivers on discharge was reduced only in GHHS group and not in the control ones. In conclusion, we can say that a GHHS continuous support allows us to reduce the family caregiver's stress. When treated at home, demented patients do not have to change their environment or routine and it is possible to have a better control on behavioral disturbances.

Is ankle/arm pressure predictive for cardiovascular mortality in older patients living in nursing homes?

AIM: To identify whether Ankle/Arm Index (AAI) is a predictive factor for cardiovascular mortality in institutionalised elderly. DESIGN: longitudinal descriptive study. SETTING: 2 large nursing homes in Turin, Italy. SUBJECTS: 418 dependent elderly (83 males, 335 females, mean age 83.7+/-8.5 y, range 55-102) living in the nursing homes. MEASUREMENTS: the prevalence of peripheral arterial disease (PAD) was evaluated using a Doppler Ultrasound measurement of AAI (Ankle/Arm blood pressure Index). Death causes according to ICD-9-CM were ascertained on patient's clinical records. RESULTS: Diagnosis of PAD was made in 122 subjects (29.2%) with AAI <0.90. After a 3 year follow-up 203 patients (48.6%) died. The presence of PAD was not related to total mortality or to mortality for ischemic heart disease (IHD), cerebrovascular disease or other causes. IHD mortality was significantly and independently related to low haemoglobin values, previous cerebrovascular disease, polypharmacy and poor mobility conditions. CONCLUSION: The prevalence of PAD is high in nursing home residents. AAI is not predictive for IHD mortality in this population. In very frail elderly traditional risk factors and PAD are less important predictors of death compared to poor functional status, nutritional factors and previous cardiovascular disease.

[Factors predicting a prolonged hospital stay in elderly patients]. / Fattori determinanti il protrarsi del ricovero nel paziente anziano.

BACKGROUND: Aim of our prospective study was to evaluate risk factors for prolonged hospitalization in elderly patients. METHODS: The study sample included 1054 patients admitted to University Department of Geriatric Medicine in Turin, Italy. We analysed: demographic variables (age, sex, marital status, economic status and living condition), affective status (GDS), cognitive status (SPMSQ), functional status (ADL-IADL), medical dependence (DMI), medical diagnosis, systolic and diastolic blood pressure, some haematological parameters (haemoglobin, creatinine, albumin, sodium, potassium). RESULTS: Average length of stays was 18+/-20.6 days; 178 patients died during hospitalization and their length of stay significantly longer (21.8+/-25.59) than survivors (17.4+/-19.3). We find that DMI dependence, impaired IADL and ADL score were associated with longer hospital stays. Medical diagnosis related to a prolonged hospitalization were: neoplasm, chronic bronchitis, hip fracture and peripheral arterial disease (PAD) with critical ischemia. Longer hospitalisation was associated also with high level of creatinine and low level of albumin and sodium. Indipendent predictors variables of prolonged hospital stay were: ADL impairment, pressure sores, hip fractures, PAD with critical ischemia, low sodium value. CONCLUSIONS: Multidimensional assessment among hospitalized elderly allows to identify risk factors for prolonged hospital stay.

[Assessment of cognitive and functional status in hospitalized elderly]. / Valutazione dello stato cognitivo e funzionale in anziani ospedalizzati.

In 1745 elderly patients (971 men and 774 women), consecutively admitted to University Geriatric Ward in San Giovanni Battista Hospital of Torino, cognitive status (SPMSQ) was evaluated. Moderate-severe and mild cognitive impairment were respectively present in 26.8% and 15.8% of the sample. Subjects affected by moderate-severe cognitive impairment were older (80.7 +/- 8.0 yrs) than patients with mild deterioration (79.5 +/- 7.8 yrs) and patients without cognitive problems (75.3 +/- 8.3 yrs). The number of pathologies and the length of hospital stay were not related to severe cognitive impairment. Lower schooling was associated with cognitive alteration. Among subjects affected by moderate-severe cognitive deterioration 15.6% was living with assistance before hospitalization. The prevalence of functional impairment (ADL) was higher (70.9%) among patients with moderate-severe cognitive impairment. In-hospital mortality was higher (21.2%) among patients with moderate-severe cognitive deterioration.

[Predictive variables of mortality in elderly patients after hospitalization. Significance of multidimensional evaluation]. / Variabili predittive di mortalità negli anziani dopo il ricovero ospedaliero. L'importanza della valutazione multidimensionale.

Functional status evaluation in the elderly is stronger predictor of hospital outcomes than type and number of pathology. Multidimensional and functional assessment among hospitalized elderly allows to identify, as well as acute and chronic illness, disabilities of sanitary problems and socio-economical aspects that in the elderly can complicate illness. Our study has identified six-month mortality post hospitalization of 20.2%. The high mortality observed in our follow-up agrees with the literature and it is a marker of considerable frailty among elderly patients. The independent predictor variables of six month post hospital mortality in the study were: male gender, dependence DMI score, low serum albumin (2.8 g/dl), impaired IADL score, cancer illness and APACHE score < 13.7. These measures represent distinct domains: demographic, functional and clinical. Identifying predictors of high-risk patients is an important way in accurate targeting.

[Polypharmacy in the ambulatory care of aged patients]. / La politerapia nella pratica ambulatoriale del paziente anziano.

The aim of this study was to assess the prevalence and possible predictors of polypharmacy in a sample of the general population. The sample consisted of 638 subjects (267 males, mean age 54.7, and 371 females, mean age 55) taken from the records of three general practitioners in the city of Turin, Italy. The prevalence of polypharmacy, for prescription drugs, was 12.5% (80 subjects). The prevalence of polypharmacy, for non prescription drugs, was 17.4% (111 subjects). The number of prescription drugs per patient rises progressively with age, averaging 2.28 and 2.5 respectively in males and in female aged older than 80 years. The number of non prescription drugs was observed to decrease with age: in women, subjects that used two or more non prescription drugs were 35% in those aged under 50 years, 20% in subjects aged from 65 to 80 years and 12.5% in those aged older than 80 years. Subjects aged older than 65 years, an IADL score < 10, more than 20 physical exams performed by practitioner in the last year, a recent hospitalisation, presence of cardiovascular disease, and presence of genito-urinary disease, were significantly and independently associated to polypharmacy for prescription drugs. Only female sex was significantly associated to polypharmacy for non prescription drugs. Our conclusion is that although age should not be involved in polypharmacy as a variable, several phenomena that influence medical treatment goals become more prevalent with increasing age and explain the high drugs consumption in the elderly. A rational, essential therapy, helped by guidelines could reduce potential problems associated with polypharmacy in the elderly.

[Sleep disorders in the aged]. / I disturbi del sonno in età avanzata.

OBJECTIVES: The aim of the study was the assessment of prevalence and risk factors of sleep disorders in the elderly. METHODS: The study sample consisted of a group of institutionalized elderly, from two university affiliated community nursing homes in Turin. The following subjects were excluded: a) those aged less than 65 years; b) had length of stay less than thirty days; c) were not able to communicate because of severe aphasia or severe hearing loss and d) had cognitive impairment based on the Short Portable Mental Status Questionnaire (SPMSQ ) > 5. A total of 88 subjects (65-102 ys; 24 male and 64 female) have been studied. Comorbidity was measured using the Acute Physiology and Chronic Health Evaluation scale (APACHE), disability using the index of Activity Daily Living (ADL), depressive symptoms using the Geriatric Depression Scale (GDS); sleep quality was determined using the Pittsburgh Sleep Quality Index (PSQI) and the subjective health by the Self-Rated Health (SRH) was also evaluated. RESULTS: Using the PSQI questionnaire, 70 subjects (79.5%) were identified as "poor sleepers" (PSQI > 5). They complained of difficulties in getting sleep (85.7%) and frequent awakening (75.7%). The most common causes of sleep disturbances were nycturia (51.4%), cough (38.6%) and pain (32.9%). Insomnia correlated with depressive symptoms, poor physical activity, number of medications and bad self-rated health. CONCLUSION: Sleep disorders probably are due to physical, psychological or ambient factors. The identification and correction of treatable causes of insomnia are relevant for improving the quality of sleep and health in the elderly.

Hypernatremic dehydration in the elderly on admission to hospital.

Dehydration is the most common cause of fluid and electrolyte disturbances in the elderly. This condition is related to the lack of increase in water intake in the presence of an increased fluid loss. The aim of this study was to evaluate the prevalence of hypernatremic dehydration in elderly patients admitted to the hospital. We retrospectively studied 2,894 subjects admitted to the acute ward of the Geriatric Section of the Department of Medical and Surgical Disciplines of the University of Torino from January 1990 to July 1995. Among them 84 (2.9%) patients, mean age 77.3 +/- 9.8 years, had serum sodium levels and blood urea nitrogen greater than 145 mEq/L and 25 mg/dL respectively with serum creatinine below 3 mg/dL. The prevalence of hypernatremic dehydration increases with age. Only 1.6% of the subjects under 65 years old are affected by this condition, against 5.3% of those over 85 years. The mortality rate observed during hospitalization is 29.8%. Mortality is positively related to serum sodium levels. We found mortality rates of 33.3% and 71.4% respectively in subjects with serum sodium levels from 151 to 153 mEq/L and in those with values over 154 mEq/L. Both serum sodium levels and age are independent risk factors for mortality (O.R. 1.31 and 1.07 respectively).

Determination of selected trace elements in patients affected by dementia.

The relationship between dementia and trace elements is widely debated. Neurotoxicity of aluminium is well recognized. The purpose of the study was to evaluate serum levels of a few trace elements and a few serum proteins in demented subjects. The study was carried out on 452 women, age range 73-88 years. Thirty one of them were affected by dementia of Alzheimer type in early or middle stages. The diagnosis had been performed by history, physical and instrumental examinations, as well as by psychometric tests. The following parameters were determined: iron, zinc, copper, serum albumin, transferrin, ceruloplasmin. Iron, copper and zinc are somewhat lower in demented subjects than in controls, but the differences are statistically not significant. The slightly diminished levels of serum albumin and transferrin in the study group may be related to a mild malnutrition. The reduction of the proteins binding trace elements, particularly of transferrin, could cause a higher bioavailability of neurotoxic trace elements such as aluminium.

Risk profile in women with stroke: role of plasma fibrinogen.

In 96 women with ischemic stroke, (mean age 77.9 +/- 7.4, S.D., years, body mass index, BMI = 23.7 +/- 3.91, we assessed the presence of risk factors for atherosclerosis, particularly of hyperfibrinogenemia. A control group of 96 women without relevant diseases, namely neoplasms, cardiovascular and inflammatory diseases, well matched for age and BMI was also studied. Subjects with stroke show higher values of systolic and diastolic blood pressure, total serum cholesterol, fibrinogen, hematocrit and more frequent habit of cigarette smoking. Levels of HDL-cholesterol, triglyceridemia and glycemia do not differ between the 2 groups. In stroke group fibrinogen is positively correlated with systolic and diastolic blood pressure and triglyceridemia. These findings confirm the presence of a risk profile for stroke, in which hypertension plays the most relevant role. The weight of fibrinogen in pathogenesis of stroke is likely to be related to the presence of other risk factors.

Hemorheolocical and photoplethysmographical modifications with aging.

The association of hemorheological patterns with the common risk factors for atherosclerosis is widely known. There are only few data about hemorheological modifications with aging. The objective of our study was to evaluate the relationships of blood and plasma viscosity, the whole blood and red cell filterability, and the amplitude of photoplethysmographical wave to aging and to some risk factors for atherosclerosis. The study involved 278 healthy women, mean age 55.3 +/- 11.9 (SD) years. Blood viscosity was positively correlated to body mass index (BMI), total cholesterol/HDL ratio, triglyceridemia, glycemia and hematocrit. Plasma viscosity was positively correlated to age, systolic blood pressure, glycemia, and fibrinogen contents. Whole blood filterability was negatively correlated to diastolic blood pressure, triglyceridemia, glycemia, hematocrit, and fibrinogen contents. Red cell filterability was negatively correlated to age, hematocrit, and fibrinogen. The amplitude of photoplethysmographical wave is inversely correlated to age and systolic blood pressure. Our findings show an increase of plasma viscosity, a decrease of red cell filterability and of the amplitude of photoplethysmographical wave with advancing age. These modifications may contribute to the microcirculatory troubles often evident in aging individuals.

Health and functional status in elderly patients living in nursing homes.

Socio-economic background, functional status, multiple pathology and medical conditions requiring care have been evaluated in 506 elderly subjects living in nursing homes in Turin (Italy). In the sample 78.8% are women, mean age 84.2 years, only 21.2% are men, mean age 76.3 years. Particularly in the oldest age classes women are more represented than men. Most subjects (94.3%) require help in at least one Activity of Daily Living (ADL). Part of the sample (21.2%) comes from home, 13.2% from acute wards, 9.1% from long term care wards, 6.3% from mental hospitals, 26.3% from residential homes. Education level is rather low. Before retirement, many men were workmen (38.3%), while many women were housewives (46.6%). Multiple pathology is very common: 23.7% of patients suffer from 4 pathologies, more than 5 diseases are present in 18.8%, while only 4.7% of subjects have less than two pathologies. Half of the sample (52.6%) is affected by dementia, 37.6% by cardiovascular diseases, 29.1% by chronic obstructive lung disease and 25.5% by stroke. Bone fractures are present in 22.1% of the subjects. Severe impairments in strength and/or motility in at least two limbs affect 43.7% of patients, double incontinence 49.2%, severe disturbances in speech and communication 35.4%. The prevalence of care needs is higher in women compared with men. More females than males need aid in walking, help in eating, diapers, pressure sores prevention and bedposts.

[Changes in the electrocardiogram in the elderly patient. The limits between normality and pathology]. / Modificazioni dell'elettrocardiogramma nell'anziano. Limiti tra normalità e patologia.

Normal electrocardiographic criteria in the elderly are not well defined. The prevalence of electrocardiographic abnormalities is three times higher in subjects over 85 years than in subjects 65-69 years old. With aging the heart rate does not vary during rest and sinus rhythm is prevalent, although sinus pauses, overall at night, are frequently seen. First degree atrio-ventricular block is present in 8.1%-19% of the elderly. 11% of subjects over 70 years suffer from left anterior hemiblock. 4.3% of subjects over 65 years and 7% of those over 85 present a right bundle branch block. 1.7% of subjects older than 65 years and 9% of those older than 85 are affected by a left bundle branch block. Atrial ectopic contractions are present in 8.8% of subjects over 60 years and in all older subjects. Atrial fibrillation is more common as age increases, being found in 2% of under 75s, in 5% of all subjects over this age, in 14% over 85 years and in 27% of patients hospitalized or institutionalized aged over 90 years. The prevalence of ventricular ectopic contractions varies from 76% in studies performed with baseline electrocardiogram to 96% in studies performed with portable monitoring electrocardiogram. Major ST-T wave alterations are present in 6.3%-13% of the elderly. In 340 patients over 80 years, hospitalized for diseases, other than cardiovascular, we found atrial fibrillation in 27.9% of subjects, ectopic beats in 26.2%, first degree atrioventricular block in 8.5%, right bundle branch block in 11.2%, left bundle branch block in 5.9%, left anterior hemiblock in 8.2%, ST-T wave alterations in 23.8% of the population.

[Neuropsychologic symptoms of primary hyperparathyroidism in the elderly. Report of a clinical case]. / Sintomatologia neuropsichica da iperparatiroidismo primitivo nell'anziano. Descrizione di un caso clinico.

Primary hyperparathyroidism is a not uncommon disease in the elderly. A prevalence of 3% for women and 1% for men is reported in subjects aged 65 years and over. Routine serum calcium determination and parathyroid hormone radioimmuno-assay allow to make an early diagnosis in still asymptomatic subjects. In the elderly the clinical features of the disease are often aspecific presenting with psychiatric and/or neuromuscular and/or cardiovascular disorders. This report refers to a 75 year-old woman admitted to our Department with a suspicion of senile dementia. She was affected by loss of memory, hallucinations, nausea, loss of appetite, mild polydipsia and polyuria. The patient was dependent in one activity of daily living (Index of Independence in Activities of Daily Living, ADL) and partially dependent in instrumental activities of daily living (Instrumental Activities of Daily Living Scale, IADL). The Short Portable Mental Status Questionnaire (SPMSQ) and the Geriatric Depression Scale (GDS) showed mild mental impairment and mild depression. Routine biochemical screening revealed a significant hypercalcemia. Parathormon assay and parathyroid scintigram were performed to confirm the diagnosis of primary hyperparathyroidism. After treatment of dehydratation and hypercalcemia, parathyroidectomy was performed: a single parathyroid adenoma was found and removed. On discharge the patient was lucid and able to carry out all ADLs and IADLs.

Hemodynamic, hemorheologic, and hemocoagulative changes after treatment with picotamide in patients affected by peripheral arterial disease (PAD) of the lower limbs.

Effects of picotamide on platelet activity and on some hemorheologic, coagulative, and hemodynamic parameters were investigated in a randomized, double-blind, placebo-controlled study for eighteen months. Twenty patients, average age 61.5 +/- 9.6 (SD) years, with peripheral arterial disease (PAD) at functional stage 2 of the Fontaine classification and with intermittent claudication for at least six months were studied. Ten patients received tablets of picotamide, 300 mg three times a day, and 10 subjects received three identical placebo tablets each day. Similar atherosclerotic disease risk factors were present in both groups. Picotamide induced a significant decrease of plasma viscosity, fibrinogen, and beta-thromboglobulin and an increase of amplitude of the photoplethysmographic wave.

Preferential looking: parameters and preliminary data of a new computerized version.

A computerized version of preferential looking (CPL) was developed by the authors. Formal parameters (spatial frequency, luminance, contrast of the stimuli; randomized procedure; computerized statistical control) and preliminary binocular acuity results in 69 healthy children (6-36 months) are compared to those of OPL, FPL and ACP version. Low cost, standardized procedure, statistical control of visual acuity estimates and the need of one operator only are among CPL advantages.