Neuroprotective role of plumbagin on eye damage induced by high-sucrose diet in adult fruit fly Drosophila melanogaster

The natural compound plumbagin has a wide range of pharmacological and potential therapeutic activities, although its role in neuroretina degeneration is unknown. Here we evaluated the effects of plumbagin on retina homeostasis of the fruit fly Drosophila melanogaster fed with high glucose diet, a model of hyperglycemia-induced eye impairment to study the pathophysiology of diabetic retinopathy at the early stages. To this aim, the visual system of flies orally administered with plumbagin has been analyzed at structural, functional, and molecular/cellular level as for instance neuronal apoptosis/autophagy dysregulation and oxidative stress-related signals. Our results demonstrated that plumbagin ameliorates the visual performance of hyperglycemic flies. Drosophila eye-structure, clearly altered by hyperglycemia, i.e. defects of the pattern of ommatidia, irregular rhabdomeres, vacuoles, damaged mitochondria, and abnormal phototransduction units were rescued, at least in part, by plumbagin. In addition, it reactivated autophagy, decreased the presence of cell death/apoptotic features, and exerted antioxidant effects in the retina. In terms of mechanisms favoring death/survival ratio, Nrf2 signaling activation may be one of the strategies by which plumbagin reduced redox unbalance mainly increasing the levels of glutathione-S-transferase. Likewise, plumbagin may act additively and/or synergistically inhibiting the mitochondrial-endoplasmic reticulum stress and unfolded protein response pathways, which prevented neuronal impairment and eye damage induced by reactive oxygen species. These results provide an avenue for further studies, which may be helpful to develop novel therapeutic candidates and drug targets against eye neurotoxicity by high glucose, a key aspect in retinal complications of diabetes.

Biomarkers of cell damage, neutrophil and macrophage activation associated with in-hospital mortality in geriatric COVID-19 patients

BACKGROUND

The risk for symptomatic COVID-19 requiring hospitalization is higher in the older population. The course of the disease in hospitalised older patients may show significant variation, from mild to severe illness, ultimately leading to death in the most critical cases. The analysis of circulating biomolecules involved in mechanisms of inflammation, cell damage and innate immunity could lead to identify new biomarkers of COVID-19 severity, aimed to improve the clinical management of subjects at higher risk of severe outcomes. In a cohort of COVID-19 geriatric patients (n= 156) who required hospitalization we analysed, on-admission, a series of circulating biomarkers related to neutrophil activation (neutrophil elastase, LL-37), macrophage activation (sCD163) and cell damage (nuclear cfDNA, mithocondrial cfDNA and nuclear cfDNA integrity). The above reported biomarkers were tested for their association with in-hospital mortality and with clinical, inflammatory and routine hematological parameters. Aim of the study was to unravel prognostic parameters for risk stratification of COVID-19 patients.

RESULTS

Lower n-cfDNA integrity, higher neutrophil elastase and higher sCD163 levels were significantly associated with an increased risk of in-hospital decease. Median (IQR) values observed in discharged vs. deceased patients were: 0.50 (0.30-0.72) vs. 0.33 (0.22-0.62) for n-cfDNA integrity; 94.0 (47.7-154.0) ng/ml vs. 115.7 (84.2-212.7) ng/ml for neutrophil elastase; 614.0 (370.0-821.0) ng/ml vs. 787.0 (560.0-1304.0) ng/ml for sCD163. The analysis of survival curves in patients stratified for tertiles of each biomarker showed that patients with n-cfDNA integrity < 0.32 or sCD163 in the range 492-811 ng/ml had higher risk of in-hospital decease than, respectively, patients with higher n-cfDNA integrity or lower sCD163. These associations were further confirmed in multivariate models adjusted for age, sex and outcome-related clinical variables. In these models also high levels of neutrophil elastase (>150 ng/ml) appeared to be independent predictor of in-hospital death. An additional analysis of neutrophil elastase in patients stratified for n-cfDNA integrity levels was conducted to better describe the association of the studied parameters with the outcome.

CONCLUSIONS

On the whole, biomarkers of cell-free DNA integrity, neutrophil and macrophage activation might provide a valuable contribution to identify geriatric patients with high risk of COVID-19 in-hospital mortality.

RACK1 is evolutionary conserved in satellite stem cell activation and adult skeletal muscle regeneration

Skeletal muscle growth and regeneration involves the activity of resident adult stem cells, namely satellite cells (SC). Despite numerous mechanisms have been described, different signals are emerging as relevant in SC homeostasis. Here we demonstrated that the Receptor for Activated C-Kinase 1 (RACK1) is important in SC function. RACK1 was expressed transiently in the skeletal muscle of post-natal mice, being abundant in the early phase of muscle growth and almost disappearing in adult mature fibers. The presence of RACK1 in interstitial SC was also detected. After acute injury in muscle of both mouse and the fruit fly Drosophila melanogaster (used as alternative in vivo model) we found that RACK1 accumulated in regenerating fibers while it declined with the progression of repair process. To note, RACK1 also localized in the active SC that populate recovering tissue. The dynamics of RACK1 levels in isolated adult SC of mice, i.e., progressively high during differentiation and low compared to proliferating conditions, and RACK1 silencing indicated that RACK1 promotes both the formation of myotubes and the accretion of nascent myotubes. In Drosophila with depleted RACK1 in all muscle cells or, specifically, in SC lineage we observed a delayed recovery of skeletal muscle after physical damage as well as the low presence of active SC in the wound area. Our results also suggest the coupling of RACK1 to muscle unfolded protein response during SC activation. Collectively, we provided the first evidence that transient levels of the evolutionarily conserved factor RACK1 are critical for adult SC activation and proper skeletal muscle regeneration, favoring the efficient progression of SC from a committed to a fully differentiated state.

Regenerative Strategies for Retinal Neurons: Novel Insights in Non-Mammalian Model Organisms

A detailed knowledge of the status of the retina in neurodegenerative conditions is a crucial point for the development of therapeutics in retinal pathologies and to translate eye research to CNS disease. In this context, manipulating signaling pathways that lead to neuronal regeneration offers an excellent opportunity to substitute damaged cells and, thus, restore the tissue functionality. Alternative systems and methods are increasingly being considered to replace/reduce in vivo approaches in the study of retina pathophysiology. Herein, we present recent data obtained from the zebrafish (Danio rerio) and the fruit fly Drosophila melanogaster that bring promising advantages into studying and modeling, at a preclinical level, neurodegeneration and regenerative approaches in retinal diseases. Indeed, the regenerative ability of vertebrate model zebrafish is particularly appealing. In addition, the fruit fly is ideal for regenerative studies due to its high degree of conservation with vertebrates and the broad spectrum of genetic variants achievable. Furthermore, a large part of the drosophila brain is dedicated to sight, thus offering the possibility of studying common mechanisms of the visual system and the brain at once. The knowledge acquired from these alternative models may help to investigate specific well-conserved factors of interest in human neuroregeneration after injuries or during pathologies.

The association between low skeletal muscle mass and delirium: results from the nationwide multi-centre Italian Delirium Day 2017

Introduction

Delirium and sarcopenia are common, although underdiagnosed, geriatric syndromes. Several pathological mechanisms can link delirium and low skeletal muscle mass, but few studies have investigated their association. We aimed to investigate (1) the association between delirium and low skeletal muscle mass and (2) the possible role of calf circumference mass in finding cases with delirium.

Methods

The analyses were conducted employing the cross-sectional “Delirium Day” initiative, on patient 65 years and older admitted to acute hospital medical wards, emergency departments, rehabilitation wards, nursing homes and hospices in Italy in 2017. Delirium was diagnosed as a 4 + score at the 4-AT scale. Low skeletal muscle mass was operationally defined as calf circumference ≤ 34 cm in males and ≤ 33 cm in females. Logistic regression models were used to investigate the association between low skeletal muscle mass and delirium. The discriminative ability of calf circumference was evaluated using non-parametric ROC analyses.

Results

A sample of 1675 patients was analyzed. In total, 73.6% of participants had low skeletal muscle mass and 24.1% exhibited delirium. Low skeletal muscle mass and delirium showed an independent association (OR: 1.50; 95% CI 1.09–2.08). In the subsample of patients without a diagnosis of dementia, the inclusion of calf circumference in a model based on age and sex significantly improved its discriminative accuracy [area under the curve (AUC) 0.69 vs 0.57, p < 0.001].

Discussion and conclusion

Low muscle mass is independently associated with delirium. In patients without a previous diagnosis of dementia, calf circumference may help to better identify those who develop delirium.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40520-021-01950-8.

Total urinary polyphenols and longitudinal changes of bone properties. The InCHIANTI study

The aim of this study was to evaluate the association of levels of urinary total polyphenols considered as a proxy measure of polyphenol intake, with longitudinal changes of bone properties, in the InCHIANTI study. Dietary intake of polyphenols appears to be associated with future accelerated deterioration of bone health.

INTRODUCTION

Polyphenols, micronutrients ingested through plant-based foods, have antioxidant and anti-inflammatory properties and may contribute to osteoporosis prevention. We evaluated associations of high levels of urinary total polyphenols (UTP), a proxy measure of polyphenol intake, with longitudinal changes of bone properties in a representative cohort of free-living participants of the InCHIANTI study.

METHODS

The InCHIANTI study enrolled representative samples from the registry list of two towns in Tuscany, Italy. Baseline data were collected in 1998 and follow-up visits in 2001 and 2004. Of the 1453 participants enrolled, 956 consented to donate a 24-h urine sample used to assess UTP, had dietary assessment, a physical examination, and underwent a quantitative computerized tomography (pQCT) of the tibia. From pQCT images, we estimated markers of bone mass (BM), diaphyseal design (DD), and material quality (MQ). Mixed models were used to study the relationship between baseline tertiles of UTP with changes of the bone characteristics over the follow-up.

RESULTS

At baseline, higher levels of UTP were positively correlated with markers of BM, DD, and MQ. Compared with lower tertile of UTP, participants in the intermediate and highest tertiles had higher cortical bone area, cortical mineral content, and cortical thickness. However, participants in the intermediate and highest UTP tertiles experienced accelerated deterioration of these same parameters over the follow-up compared with those in the lowest UTP tertile.

CONCLUSIONS

Dietary intake of polyphenols estimated by UTP and dietary questionnaire was associated with long-term accelerated deterioration of bone health. Our study does not support the recommendation of increasing polyphenol intake for osteoporosis prevention.

Risk of amyotrophic lateral sclerosis and exposure to particulate matter: A case-control study

Background

Amyotrophic lateral sclerosis (ALS) is fatal neurodegenerative disease with still unknown etiology. Some environmental and occupational risk factors have been proposed, including air pollution, as suggested by recent studies. We carried out a case-control study in order to assess ALS risk due to environmental exposure to particulate matter ≤10 µm (PM10).

Methods

We recruited ALS patients referred to the Modena Neurology Unit between 1994-2015 and a reference group sampled from the population of Modena province. Using a geographical information system-based dispersion model, we estimated outdoor air PM10 levels at the geocoded subjects' addresses of residence at the time of diagnosis. We computed odds ratio (OR) and 95% confidence interval (CI) of ALS according to increasing PM10 exposure, using an unconditional logistic regression model adjusted for age and sex.

Results

For the study 132 participants (52 cases/80 controls), mean of annual average and maximum PM10 levels were 5.2 and 38.6 µg/m3, respectively. Using fixed cutpoints at 5, 10 and 20 of average annual PM10 levels, compared with subjects &lt;5 µg/m3, we did not find an excess ALS risk associated with PM10 exposure, since OR was 0.87 (95%CI 0.39-1.96), 0.94 (0.24-3.70), and 0.87 (0.05-15.01) at 5-10, 10-20 and ≥20 µg/m3, respectively. When using maximum annual PM10 levels, we found an excess ALS risk for subjects exposed at 10-20 µg/m3 (OR = 4.27, 0.69-26.51) compared with exposure below 10 µg/m3. However, risk decreased with further exposure increase at 20-50 (OR = 1.49, 0.39-5.75), and ≥50 µg/m3 (OR = 1.16, 0.98-4.82).

Conclusions

Our findings do not suggest that PM10 exposure is associated with ALS risk, even at the high levels of exposure characterizing a Northern Italy province. However, the statistically imprecise increased risks associated with maximum annual exposure levels suggest the need of further investigations.

Key messages

Outdoor particulate matter exposure seems not associated risk of amyotrophic lateral sclerosis. Only exposure to high concentrations of particulate matter might increase risk of amyotrophic lateral sclerosis.

Exposure to particulate matter and risk of dementia in subjects with mild cognitive impairment

Background

Exposure to air pollutants increases the risk of several chronic diseases, possibly including neurodegenerative disease such as Alzheimer's dementia. In this study, we aimed to evaluate the effect of long-term exposure to as major outdoor air pollutant, particulate matter ≤10μm (PM10), on the risk of dementia in a cohort of subjects with mild cognitive impairment.

Methods

We recruited a cohort of 53 subjects newly diagnosed with mild cognitive impairment residing in Modena and Reggio Emilia provinces. We geocoded their residence address, and we estimated their exposure to PM10 from motorized traffic using a validated air dispersion model. We investigated the relation of baseline exposure to subsequent conversion to dementia using a Cox proportional hazards model. We computed hazard ratio (HR) and 95% confidence interval (CI) of dementia according to increasing PM10 exposure, adjusting for sex, age, and education.

Results

During a median follow-up of 42 months, 24 participants developed dementia, 19 of Alzheimer's type. Baseline average PM10 exposure concentrations were 9.6µg/m3. Using PM10 levels below 5µg/m3 as reference, we found a dose-response increase in any dementia risk, with a HR of 1.04 (95% CI 0.41-2.66) 5-10µg/m3, 1.32 (95% CI 0.36-4.92) at 10-20µg/m3, and 1.38 (95% CI 0.14-13.13) above 20µg/m3.

Conclusions

Using a cohort study design, we found that exposure to outdoor PM10 was associated with increased risk of conversion from mild cognitive impairment to dementia. However, the limited study size suggests caution in the interpretation of this finding.

Key messages

Air pollution may be a risk factor for dementia. Dementia risk may be linked to modifiable environmental risk factors.

Is the fast-track process efficient and safe for older adults admitted to the emergency department?

BACKGROUND

The efficiency of the fast-track (FT) process in the management of patients in Emergency Departments is well demonstrated, but there is a lack of research focused on older adults. The aim of our study was to verify whether the FT process is efficient and safe for older adults admitted to ED.

METHODS

Observational case-control single-centre study.

RESULTS

Five hundred four cases and 504 controls were analysed. The mean age was 75 years, and there was a predominance of women. In total 96% of subjects were classified with a "less-urgent" tag. The length of stay was significantly lower in the fast-track group than in the control group (median 178 min, interquartile range 184 min, and 115 min, interquartile range 69 min, respectively, p < 0.001), as well as the time spent between the ED physician's visit and patient discharge (median 78 min, interquartile range 120 min, and median 3 min, interquartile range 6 min, respectively, p < 0.001). There weren't any increases in the number of unplanned readmissions within 48 h, 7 days and 30 days.

CONCLUSIONS

The fast-track appears to be an efficient and safe strategy to improve the management of older adults admitted to the ED with minor complaints.

Texture-Modified Diet for Improving the Management of Oropharyngeal Dysphagia in Nursing Home Residents: An Expert Review

OBJECTIVES

This paper provides evidence-based and, when appropriate, expert reviewed recommendations for long-stay residents who are prescribed texture-modified diets (TMDs), with the consideration that these residents are at high risk of worsening oropharyngeal dysphagia (OD), malnutrition, dehydration, aspiration pneumonia, and OD-associated mortality, poorer quality of life and high costs.

DESIGN

Nestlé Health Science funded an initial virtual meeting attended by all authors, in which the unmet needs and subsequent recommendations for OD management were discussed. The opinions, results, and recommendations detailed in this paper are those of the authors, and are independent of funding sources.

SETTING

OD is common in nursing home (NH) residents, and is defined as the inability to initiate and perform safe swallowing. The long-stay NH resident population has specific characteristics marked by a shorter life expectancy relative to community-dwelling older adults, high prevalence of multimorbidity with a high rate of complications, dementia, frailty, disability, and often polypharmacy. As a result, OD is associated with malnutrition, dehydration, aspiration pneumonia, functional decline, and death. Complications of OD can potentially be prevented with the use of TMDs.

RESULTS

This report presents expert opinion and evidence-informed recommendations for best practice on the nutritional management of OD. It aims to highlight the practice gaps between the evidence-based management of OD and real-world patterns, including inadequate dietary provision and insufficient staff training. In addition, the unmet need for OD screening and improvements in therapeutic diets are explored and discussed.

CONCLUSION

There is currently limited empirical evidence to guide practice in OD management. Given the complex and heterogeneous population of long-stay NH residents, some 'best practice' approaches and interventions require extensive efficacy testing before further changes in policy can be implemented.

EuGMS Task and Finish group on Fall-Risk-Increasing Drugs (FRIDs): Position on Knowledge Dissemination, Management, and Future Research

Falls are a major public health concern in the older population, and certain medication classes are a significant risk factor for falls. However, knowledge is lacking among both physicians and older people, including caregivers, concerning the role of medication as a risk factor. In the present statement, the European Geriatric Medicine Society (EuGMS) Task and Finish group on fall-risk-increasing drugs (FRIDs), in collaboration with the EuGMS Special Interest group on Pharmacology and the European Union of Medical Specialists (UEMS) Geriatric Medicine Section, outlines its position regarding knowledge dissemination on medication-related falls in older people across Europe. The EuGMS Task and Finish group is developing educational materials to facilitate knowledge dissemination for healthcare professionals and older people. In addition, steps in primary prevention through judicious prescribing, deprescribing of FRIDs (withdrawal and dose reduction), and gaps in current research are outlined in this position paper.

EuGMS Task and Finish group on Fall-Risk-Increasing Drugs (FRIDs): Position on Knowledge Dissemination, Management, and Future Research

Falls are a major public health concern in the older population, and certain medication classes are a significant risk factor for falls. However, knowledge is lacking among both physicians and older people, including caregivers, concerning the role of medication as a risk factor. In the present statement, the European Geriatric Medicine Society (EuGMS) Task and Finish group on fall-risk-increasing drugs (FRIDs), in collaboration with the EuGMS Special Interest group on Pharmacology and the European Union of Medical Specialists (UEMS) Geriatric Medicine Section, outlines its position regarding knowledge dissemination on medication-related falls in older people across Europe. The EuGMS Task and Finish group is developing educational materials to facilitate knowledge dissemination for healthcare professionals and older people. In addition, steps in primary prevention through judicious prescribing, deprescribing of FRIDs (withdrawal and dose reduction), and gaps in current research are outlined in this position paper.

A Fully Automated, Atlas-Based Approach for Superior Cerebellar Peduncle Evaluation in Progressive Supranuclear Palsy Phenotypes

BACKGROUND AND PURPOSE

The superior cerebellar peduncle is damaged in progressive supranuclear palsy. However, alterations differ between progressive supranuclear palsy with Richardson syndrome and progressive supranuclear palsy-parkinsonism. In this study, we propose an automated tool for superior cerebellar peduncle integrity assessment and test its performance in patients with progressive supranuclear palsy with Richardson syndrome, progressive supranuclear palsy-parkinsonism, Parkinson disease, and healthy controls.

MATERIALS AND METHODS

Structural and diffusion MRI was performed in 21 patients with progressive supranuclear palsy with Richardson syndrome, 9 with progressive supranuclear palsy-parkinsonism, 20 with Parkinson disease, and 30 healthy subjects. In a fully automated pipeline, the left and right superior cerebellar peduncles were first identified on MR imaging by using a tractography-based atlas of white matter tracts; subsequently, volume, mean diffusivity, and fractional anisotropy were extracted from superior cerebellar peduncles. These measures were compared across groups, and their discriminative power in differentiating patients was evaluated in a linear discriminant analysis.

RESULTS

Compared with those with Parkinson disease and controls, patients with progressive supranuclear palsy with Richardson syndrome showed alterations of all superior cerebellar peduncle metrics (decreased volume and fractional anisotropy, increased mean diffusivity). Patients with progressive supranuclear palsy-parkinsonism had smaller volumes than those with Parkinson disease and controls and lower fractional anisotropy than those with Parkinson disease. Patients with progressive supranuclear palsy with Richardson syndrome had significantly altered fractional anisotropy and mean diffusivity in the left superior cerebellar peduncle compared with those with progressive supranuclear palsy-parkinsonism. Discriminant analysis with the sole use of significant variables separated progressive supranuclear palsy-parkinsonism from progressive supranuclear palsy with Richardson syndrome with 70% accuracy and progressive supranuclear palsy-parkinsonism from Parkinson disease with 74% accuracy.

CONCLUSIONS

We demonstrate the feasibility of an automated approach for extracting multimodal MR imaging metrics from the superior cerebellar peduncle in healthy subjects and patients with parkinsonian. We provide evidence that structural and diffusion measures of the superior cerebellar peduncle might be valuable for computer-aided diagnosis of progressive supranuclear palsy subtypes and for differentiating patients with progressive supranuclear palsy-parkinsonism from with those with Parkinson disease.

Baseline Frailty Evaluation in Drug Development

Older people are high consumers of medicines, but despite this they have often been excluded from clinical trials. Reasons for exclusion have frequently been poorly justifiable, and have included predefined arbitrary upper age limits, lists of different comorbidities, polypharmacy or physician/patient/family preference. This selection bias is even more evident for the frail older adults. Consequently, the evidence base in this age group is often limited at the time of market authorisation. The benefit/risk analysis for the frail older adult may well be different from that of younger people, and a lack of data may result in inappropriate prescribing.

The European Union Geriatric Medicine Society (EUGMS) Working Group on «Frailty in Older Persons»

The concept of frailty was introduced in literature to help atclinically depicting the transition of a robust older individualinto a different clinical phenotype of risk (1-5). Frailty isgenerally described as a multisystemic impairment responsiblefor a state of increased vulnerability to endogenous andexogenous stressors (6, 7). This syndrome may represent thefirst step towards the evident and clinically relevant functionaldisability (a cornerstone outcome for geriatric medicine)8, andhas shown to be predictive of major negative health-relatedevents, including

Operationalization of the physical frailty & sarcopenia syndrome: rationale and clinical implementation

Over the years, different operational definitions have been elaborated to identify frail older persons, but none of them has received unanimous consensus. This, in turn, has hampered the clinical implementation of frailty as well as the design of targeted interventions. To overcome the current limitations in the field, a novel operationalization of physical frailty (PF) is proposed which grounds its roots in the recognition of sarcopenia as its central biological substrate. This conceptualization is based on the fact that the clinical picture of PF overlaps substantially with that of sarcopenia. The two conditions may therefore be merged into a new clinical entity, the PF & sarcopenia (PF&S) syndrome, in which muscle loss represents both the biological substrate for the development of PF and a major pathway whereby the negative health outcomes of PF occur. All of the components defining the PF&S syndrome are measurable in an objective manner, which will facilitate its incorporation into standard practice. The recognition of a precise biological substratum for PF&S (i.e., skeletal muscle decline) also opens new venues for the development of preventive and therapeutic interventions.

Association between Both Total Baseline Urinary and Dietary Polyphenols and Substantial Physical Performance Decline Risk in Older Adults: A 9-year Follow-up of the InCHIANTI Study

IMPORTANCE

The decline in physical performance that occurs in many older subjects is a strong predictor of falls, hospitalization, institutionalization and mortality. Polyphenols are bioactive compounds that may play a preventive role against physical performance decline due to their antioxidant and anti-inflammatory properties.

OBJECTIVE

To investigate the association between total urinary polyphenols (TUP) and total dietary polyphenols (TDP) and substantial physical performance decline over a nine-year period among older subjects.

METHODS

This longitudinal study included 368 participants aged 65 years or older from the InCHIANTI (Invecchiare in Chianti) study, an Italian population-based cohort. TUP and TDP concentrations were assessed at baseline using the Folin-Ciocalteau (F-C) assay and a validated food frequency questionnaire, respectively. Physical performance was objectively measured at baseline and at nine-year follow-up using the Short Physical Performance Battery (SPPB). A substantial decline in physical performance was considered as a decrease of three or more points in the SPPB score.

RESULTS

At the nine-year follow-up assessment, 71 participants had suffered a substantial decline in physical performance. In the fully adjusted logistic regression model, participants in the highest TUP tertile had a lower risk of substantial decline in physical performance than those in the lowest tertile (OR, 0.40; 95% CI, 0.17-0.93; P trend=0.033). However, no significant association between TDP intake and physical performance decline was observed.

CONCLUSION

This study shows that high TUP concentrations, a biomarker of polyphenol-rich exposure, were associated with lower risk of substantial decline in physical performance in community-dwelling older subjects over a nine-year period. These results suggest that a polyphenol-rich diet may play a role in protecting against physical performance decline in older people.

Non-Pharmacological Interventions to Prevent or Treat Delirium in Older Patients: Clinical Practice Recommendations The SENATOR-ONTOP Series

DESCRIPTION

The ONTOP project aims to undertake a literature search of systematic reviews concerning evidence-based non-pharmacological interventions of prevalent medical conditions affecting older people, including delirium.

OBJECTIVES

To develop explicit and transparent recommendations for non-pharmacological interventions in older subjects at risk of developing delirium, as well as in older subjects with delirium, based on the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach to rating the quality of evidence and the strength of recommendations.

METHODS

A multidisciplinary panel was constituted comprising geriatricians, research nurse and a clinical epidemiologist. The panel developed a systematic overview of non-pharmacological interventions to prevent or treat delirium. The GRADE approach was used to rate the evidence and to formulate recommendations.

RESULTS

The critical outcomes were delirium incidence, for delirium prevention, and delirium improvement and functional status, for delirium treatment. The non-pharmacological interventions were identified and categorized as multicomponent and single component. Strong recommendations in favor of multicomponent interventions to prevent delirium, in surgical or medicals wards, were formulated. In the latter case the evidence applied to older patients at intermediate - high risk of developing delirium. Weak recommendations, to prevent delirium, were formulated for multicomponent interventions provided by family members (medical ward), staff education (medical ward), ear plugs (intensive care unit), reorientation protocol (intensive care unit), and the use of a software to perform drug review. Weak recommendations were provided for the use of multicomponent interventions to prevent delirium in medical wards in patients not selected according to the risk of delirium. Strong recommendations not to use bright light therapy to prevent delirium in intensive care unit settings were articulated. Weak recommendations not to use music therapy to prevent delirium for patients undergoing surgical interventions were specified. The ability to make strong recommendations was limited by the low quality of evidence and the presence of uncertainty. Moreover, weak recommendations were provided for the use of multicomponent interventions to treat delirium of older patients (medical wards).

CONCLUSIONS

Overall, the panel developed 12 recommendations for the delivery of non-pharmacological interventions to older patients at risk of developing or, with delirium.

Diagnosing and treating depression in older and oldest old

Depression is very common in older people and it is associated with negative consequences such as functional decline, increased morbidity and mortality and higher healthcare costs. Despite this, it is still underdiagnosed and undertreated and the issue is particularly relevant for people older than 80 years. The main reasons for underdiagnosis are: atypical presentation, concomitant cognitive decline, inadequate diagnostic tools, and prejudice that depression is a normal part of ageing. On the other hand, the main reasons for undertreatment are: multimorbidity, concerns about adverse events and drug interactions, lack of confidence in the efficacy and safety of pharmacological and non-pharmacological treatments in the oldest old depressed patients, who are underrepresented in clinical studies. The new antidepressants are the drugs most frequently used, due to their perceived more favorable safety profile than older antidepressants. Psychotherapy is equally effective but less frequently used and should request some adaptive strategies for the peculiarities of octogenarians. Electroconvulsive therapy is limited to severe psychotic late-life depression resistant to other treatments. In light of the heterogeneity of people aged 80 years and over, with multiple and different medical, functional, socioeconomic problems, a multidimensional approach is probably the most suitable both for diagnosis and treatment, in order to develop an individualized care plan. These considerations should guide the formulation of future research studies, specifically tailored for the oldest depressed patients.

3-T magnetic resonance imaging simultaneous automated multimodal approach improves detection of ambiguous visual hippocampal sclerosis

BACKGROUND AND PURPOSE

To evaluate if an automatic magnetic resonance imaging (MRI) processing system may improve detection of hippocampal sclerosis (Hs) in patients with mesial temporal lobe epilepsy (MTLE).

METHODS

Eighty consecutive patients with a diagnosis of MTLE and 20 age- and sex-matched controls were prospectively recruited and included in our study. The entire group had 3-T MRI visual assessment of Hs analysed by two blinded imaging epilepsy experts. Logistic regression was used to evaluate the performances of neuroradiologists and multimodal analysis.

RESULTS

The multimodal automated tool gave no evidence of Hs in all 20 controls and classified the 80 MTLE patients as follows: normal MRI (54/80), left Hs (14/80), right Hs (11/80) and bilateral Hs (1/80). Of note, this multimodal automated tool was always concordant with the side of MTLE, as determined by a comprehensive electroclinical evaluation. In comparison with standard visual assessment, the multimodal automated tool resolved five ambiguous cases, being able to lateralize Hs in four patients and detecting one case of bilateral Hs. Moreover, comparing the performances of the three logistic regression models, the multimodal approach overcame performances obtained with a single image modality for both the hemispheres, reaching a global accuracy value of 0.97 for the right and 0.98 for the left hemisphere.

CONCLUSIONS

Multimodal quantitative automated MRI is a reliable and useful tool to depict and lateralize Hs in patients with MTLE, and may help to lateralize the side of MTLE especially in subtle and uncertain cases.

Toward an affordable and user-friendly visual motion capture system

The present study aims at designing and evaluating a low-cost, simple and portable system for arm joint angle estimation during grasping-like motions. The system is based on a single RGB-D camera and three customized markers. The automatically detected and tracked marker positions were used as inputs to an offline inverse kinematic process based on bio-mechanical constraints to reduce noise effect and handle marker occlusion. The method was validated on 4 subjects with different motions. The joint angles were estimated both with the proposed low-cost system and, a stereophotogrammetric system. Comparative analysis shows good accuracy with high correlation coefficient (r= 0.92) and low average RMS error (3.8 deg).

The Relationship of Hemoglobin Levels, Delirium and Cognitive Status in Hospitalized Geriatric Patients: Results from the CRIME Study

OBJECTIVE

Delirium is a frequent clinical complication in geriatric patients admitted to the hospital, because of the simultaneous presence and synergistic effect of predisposing and precipitating factors. Also anaemia is a common concern in geriatric population. The aim of this study was to investigate the association between anaemia (precipitating factor) and delirium in a sample of Italian older hospitalized patients with different degree of cognitive impairment (predisposing factor).

DESIGN, SETTING, PARTICIPANTS

Cross-sectional analysis of 1069 participants enrolled in the CRIME study, with assessment of hemoglobin levels at hospital admission.

MEASUREMENTS

Delirium was assessed using DSM-IV criteria, whereas cognitive status was categorized as dementia, cognitive impairment or normal, according to clinical history, specific treatment and MMSE score. Anaemia was defined according to sex-specific WHO criteria. The association of hemoglobin levels and delirium was investigated with multivariable logistic regression models.

RESULTS

Mean age of study participants was 81.4±7.2 years, 52.2% had prevalent anaemia, 6.1% had delirium. According to cognitive status 20.8% had dementia and 40.9% had cognitive impairment. Overall there was no association between anaemia and delirium. However, among patients with cognitive impairment (MMSE <24, no dementia) anaemia was significantly associated with the likelihood of delirium (p<0.006). Multivariate logistic regression analysis, adjusted for potential confounders, showed in these patients a graded increased risk of delirium according to anaemia severity with an almost six-fold increased risk of delirium in moderate-severe anaemia (OR 5.95, 95% CI:1.15-30.73).

CONCLUSION

In older patients with cognitive impairment moderate-severe anaemia is independently associated with the likelihood of delirium. Further studies should investigate if anaemia correction would translate in delirium risk reduction.

Physical performance measures and polypharmacy among hospitalized older adults: results from the CRIME study

OBJECTIVE

To investigate the association of polypharmacy and physical performance measures in a sample of elderly patients aged ≥65 years admitted to acute care hospitals.

DESIGN, SETTING AND PARTICIPANTS

Prospective study conducted among 1123 hospitalized older adults participating to the CRiteria to Assess Appropriate Medication Use among Elderly Complex Patients (CRIME) project.

MEASUREMENTS

Physical performance was measured at hospital admission by the 4-meter walking speed (WS) and the grip strength (GS). Polypharmacy was defined as the use of ≥10 drugs during hospital stay.

RESULTS

Mean age of 1123 participants was 81.5±7.4 years and 576 (51.3%) were on polypharmacy. Prevalence of polypharmacy was higher in patients with low WS and GS. After adjusting for potential confounders, participants in the highest tertile of WS were less likely to be on polypharmacy as compared with those in the lowest tertile (OR 0.58; 95% CI 0.35 - 0.96). Similarly, participants in the highest tertile of GS had a significantly lower likelihood of polypharmacy as compared with those in the lowest tertile (OR 0.55; 95% CI 0.36 - 0.84). When examined as continuous variables, WS and GS were inversely associated with polypharmacy (WS: OR 0.77 per 1 SD increment; 95% CI 0.60 - 0.98; GS: OR 0.71 per 1 SD increment; 95% CI 0.56 - 0.90).

CONCLUSION

Among hospitalized older adults WS and GS are inversely related to polypharmacy. These measures should be incorporated in standard assessment of in-hospital patients.