Quadriplegia due to pachymeningitis, vasculitis and sepsis in a patient with rheumatoid arthritis: a case report

We report the case of a 84-year-old man, with history of rheumatoid arthritis, admitted the Hospital for a fall and complaining of dysaesthesia and pain located to the cervical spine and arms. Within a few hours after admission, fever and acute, progressive, ascendant quadriplegia became evident. Magnetic resonance imaging (MRI) of cervical spine showed spinal canal stenosis between C4-C6 with spinal cord compression. Hemocultures resulted positive for Staphylococcus aureus. The clinical picture rapidly evolved to sepsis with a fatal multi-organ failure. An autopsy found a osteosclerosis narrowing the neurocanal at the level of C3-C6, and recent cervical medulla infarction. A histological exam revealed the presence of a suppurative pachymeningitis with local phenomenas of periradiculitis, vasculitis and thrombosis of the anterior medullar artery, associated with coagulative necrosis of the neural tissue.

Potentially inappropriate drug prescriptions and risk of hospitalization among older, Italian, nursing home residents: the ULISSE project

BACKGROUND

Potentially inappropriate medications in older patients increase the risk of adverse drug events, which are an important cause of hospital admission and death among hospitalized patients. Little information is available about the prevalence of potentially inappropriate drug prescriptions (PIDPs) and the related health adverse outcomes among nursing home (NH) residents.

OBJECTIVE

To estimate the prevalence of PIDPs and the association with adverse outcomes in NH residents.

METHODS

A total of 1716 long-term residents aged >or=65 years participating in the ULISSE (Un Link Informatico sui Servizi Sanitari Esistenti per l'anziano [A Computerized Network on Health Care Services for Older People]) project were evaluated using a standardized comprehensive geriatric assessment instrument, i.e. the interResident Assessment Instrument Minimum Data Set. A thorough evaluation of residents' drug use, medical diagnoses and healthcare resource utilization was performed. A PIDP was defined according to the most recent update of the Beers criteria.

RESULTS

Almost one out of two persons (48%) had at least one PIDP and almost one out of five had two or more PIDPs (18%). Residents with a higher number of PIDPs had a higher likelihood of being hospitalized. Compared with residents without PIDPs, those with two or more PIDPs at baseline had a higher probability of being hospitalized (hazard ratio 1.73; 95% CI 1.14, 2.60) during the following 12 months. Risk of PIDP was positively associated with the total number of drugs and diseases, but negatively with age. PIDPs defined according to specific conditions (n = 780; 55%) were slightly more frequent than PIDPs based on single medications irrespective of specific indication (n = 639; 45%).

CONCLUSIONS

PIDP is a significant problem among Italian NH residents. There is an urgent need for intervention trials to test strategies to reduce inappropriate drug use and its associated adverse health outcomes.

Predictive value of the Short Physical Performance Battery following hospitalization in older patients

BACKGROUND

Hospitalization represents a stressful and potentially hazardous event for older persons. We evaluated the value of the Short Physical Performance Battery (SPPB) in predicting rates of functional decline, rehospitalization, and death in older acutely ill patients in the year after discharge from the hospital.

METHODS

Prospective cohort study of 87 patients aged 65 years and older who were able to walk and with a Mini-Mental State Examination score ≥ 18 and admitted to the hospital with a clinical diagnosis of congestive heart failure, pneumonia, chronic obstructive pulmonary disease, or minor stroke. Patients were evaluated with the SPPB at hospital admission, were reevaluated the day of hospital discharge, and 1 month later. Subsequently, they were followed every 3 months by telephone interviews to ascertain functional decline, new hospitalizations, and vital status.

RESULTS

After adjustment for potential confounders, including self-report activity of daily living and comorbidity, the SPPB score at discharge was inversely correlated with the rate of decline in activity of daily living performance over the follow-up (p < .05). In a multivariable discrete-time survival analysis, patients with poor SPPB scores at hospital discharge (0-4) had a greater risk of rehospitalization or death (odds ratio: 5.38, 95% confidence interval: 1.82-15.9) compared with those with better SPPB scores (8-12). Patients with early decline in SPPB score after discharge also had steeper increase in activity of daily living difficulty and higher risk of rehospitalization or death over the next year.

CONCLUSIONS

In older acutely ill patients who have been hospitalized, the SPPB provides important prognostic information. Lower extremity performance-based functional assessment might identify older patients at high risk of poor outcomes after hospital discharge.

Development of CRIteria to assess appropriate Medication use among Elderly complex patients (CRIME) project: rationale and methodology

Pharmacological treatment of complex older adults with comorbidities, multiple impairments in function, cognition, social status and geriatric syndromes represents a challenge for prescribing physicians and often results in a high rate of iatrogenic illnesses. Clinical guidelines are commonly used to indicate appropriate prescription, but they are often based on the results of clinical trials that are conducted on young subjects with a low level of complexity. Therefore, the recommendations of clinical guidelines may be difficult to apply to older complex adults. In this paper we present the rationale and methodology of the Development of CRIteria to assess appropriate Medication use among Elderly complex patients (CRIME) project, a study aimed at producing recommendations to evaluate the appropriateness of pharmacological prescription in older complex patients, translating the recommendations of clinical guidelines to this type of patient. A literature search will be performed to integrate and revise the recommendations of disease-specific guidelines on the pharmacological treatment of patients with common chronic conditions. New recommendations will be provided and approved in a consensus meeting of international experts. Both data from randomized controlled trials and observational studies will be used to meet this aim. Recommendations provided by the CRIME project are not meant to replace existing clinical guidelines, but they may be used to help physicians in the prescribing process. Once completed these recommendations should be validated in interventional studies.

Lipoprotein(a), inflammation, and peripheral arterial disease in a community-based sample of older men and women (the InCHIANTI study)

Lipoprotein(a) (Lp[a]) may represent an independent risk factor for peripheral arterial disease of the lower limbs (LL-PAD), but prospective data are scant. We estimated the association between baseline Lp(a) with prevalent and incident LL-PAD in older subjects from the InCHIANTI Study. LL-PAD, defined as an ankle-brachial index <0.90, was assessed at baseline and over a 6-year follow-up in a sample of 1,002 Italian subjects 60 to 96 years of age. Plasma Lp(a) and potential traditional and novel cardiovascular risk factors (including a score based on relevant inflammatory markers) were entered in multivariable models to assess their association with prevalent and incident LL-PAD. At baseline, Lp(a) concentration was directly related to the number of increased inflammatory markers (p <0.05). There were 125 (12.5%) prevalent cases of LL-PAD and 57 (8.3%) incident cases. After adjustment for potential confounders, participants in the highest quartile of the Lp(a) distribution (>/=32.9 mg/dl) were more likely to have LL-PAD compared to those in the lowest quartile (odds ratio [OR] 1.83, 95% confidence interval [CI] 1.01 to 3.33). The association was stronger (OR 3.80, 95% CI 1.50 to 9.61) if LL-PAD was defined by harder criteria, namely an ankle-brachial index <0.70. Compared to subjects in the lowest Lp(a) quartile, those in the highest quartile showed a somewhat increased risk of incident LL-PAD (lowest quartile 7.7%, highest quartile 10.8%), but the association was not statistically significant (OR 1.52, 95% CI 0.71 to 3.22). In conclusion, Lp(a) is an independent LL-PAD correlate in the cross-sectional evaluation, but further prospective studies in larger populations, with longer follow-up and more definite LL-PAD ranking, might be needed to establish a longitudinal association.

Type 2 diabetes and risk for functional decline and disability in older persons

As older adults make up an increasingly lager proportion of the diabetic population, the spectrum of chronic diabetes complications will change and expand. Aside from the traditional long-term complications, diabetes has been associated with excess risk of a number of clinical conditions typical of the geriatric population, including functional decline, physical disability, falls, fractures, cognitive impairment, and depression. These conditions are common and profoundly affect the quality of life of older patients with diabetes. The identification of effective ways of preventing and treating these emerging complications, thus improving quality of life among older diabetic patients, is already a major issue in geriatric medicine. In this narrative review, we describe current epidemiological and clinical evidence supporting the association between diabetes and physical disability in older persons. Furthermore, the potential biological mechanisms underlying such an association are analyzed.

Moderate alcohol intake and risk of functional decline: the Health, Aging, and Body Composition study

OBJECTIVES

To investigate the prospective relationship between alcohol consumption and incident mobility limitation.

DESIGN

Cohort study.

SETTING

The Health Aging and Body Composition study, conducted in Memphis, Tennessee, and Pittsburgh, Pennsylvania.

PARTICIPANTS

Three thousand sixty-one adults aged 70 to 79 without mobility disability at baseline.

MEASUREMENTS

Incidence of mobility limitation, defined as self-report at two consecutive semiannual interviews of any difficulty walking one-quarter of a mile or climbing stairs, and incidence of mobility disability, defined as severe difficulty or inability to perform these tasks at two consecutive reports. Alcohol intake, lifestyle-related variables, diseases, and health status indicators were assessed at baseline.

RESULTS

During a follow-up time of 6.5 years, participants consuming moderate levels of alcohol had the lowest incidence of mobility limitation (total: 6.4 per 100 person-years (person-years); men: 6.4 per 100 person-years; women: 7.3 per 100 person-years) and mobility disability (total: 2.7 per 100 person-years; men: 2.5 per 100 person-years; women: 2.9 per 100 person-years). Adjusting for demographic characteristics, moderate alcohol intake was associated with lower risk of mobility limitation (hazard ratio (HR)=0.70, 95% confidence interval (CI)=0.55-0.89) and mobility disability (HR=0.66, 95% CI=0.45-0.95) than never or occasional consumption. Additional adjustment for lifestyle-related variables substantially reduced the strength of the associations (HR=0.85, 95% CI=0.66-1.08 and HR=0.81, 95% CI=0.56-1.18, respectively). Adjustment for diseases and health status indicators did not affect the strength of the associations, suggesting that lifestyle is most important in confounding this relationship.

CONCLUSION

Lifestyle-related characteristics mainly accounted for the association between moderate alcohol intake and lower risk of functional decline over time. These findings do not support a direct causal effect of alcohol intake on physical function.

Performance-based functional assessment in older hospitalized patients: feasibility and clinical correlates

BACKGROUND

Functional evaluation is a cornerstone of multidimensional geriatric assessment; however, little is known of the clinical value of standardized performance-based assessment in the acute care setting. The aim of this study was to evaluate the clinical correlates and short-term predictive value of the Short Physical Performance Battery (SPPB) in older patients admitted to the hospital for an acute medical event.

METHODS

We enrolled 92 women and men 65 years old or older who were able to walk, who had a Mini-Mental State Examination (MMSE) score > or =18, and who were admitted to the hospital with a clinical diagnosis of congestive heart failure, pneumonia, chronic obstructive pulmonary disease (COPD), or minor stroke. The SPPB was assessed at hospital admission and discharge. Self-report functional assessment included basic activities of daily living (ADL) and instrumental activities of daily living (IADL). Spearman's rank correlation coefficients and multivariable linear regression analyses were used to study the association of SPPB score and functional and clinical characteristics, including length of hospital stay.

RESULTS

The mean age was 77.7 years (range 65-94 years), 49% were female, 64.1% had congestive heart failure, 16% COPD, 13.1% pneumonia, and 6.5% minor stroke. At hospital admission the mean SPPB score was 6.0 +/- 2.7. SPPB scores were inversely correlated with age, the severity of the index disease, and IADL and ADL difficulty 2 weeks before hospital admission (p <.01), and were directly correlated with MMSE score (p =.002). On average, SPPB score increased 1 point (+0.97, standard error of the mean = 0.2; p for paired t test <.001) from baseline to hospital discharge assessment. After adjustment for potential confounders, baseline SPPB score was significantly associated with the length of hospital stay (p <.007).

CONCLUSION

In older acute care inpatients, SPPB is a valid indicator of functional and clinical status. SPPB score at hospital admission is an independent predictor of the length of hospital stay.

Physical function, physical activity and recent falls. Results from the "Invecchiamento e Longevità nel Sirente (ilSIRENTE)" Study

BACKGROUND AND AIMS

A fall is a common and traumatic event in the life of older persons. This study aims: 1) to explore the relationship between recent falls and measures of physical function in elders, and 2) to examine the role played by habitual physical activity in the relationship between recent falls and physical function.

METHODS

We used baseline data from 361 community-dwelling persons aged > or = 80 years (mean age 85.9 yrs) enrolled in the "Invecchiamento e Longevità nel Sirente (ilSIRENTE)" study. Physical performance was assessed using the Short Physical Performance Battery (SPPB) and usual gait speed. Muscle strength was measured by hand grip strength. Functional status was assessed by the Basic (ADL) and Instrumental Activities of Daily Living (IADL) scales. Self-reported recent falls over the previous three months were recorded. Analyses of covariance were performed to evaluate the relationship between recent fall events and physical function measures.

RESULTS

Fifty participants (13.9%) reported at least one recent fall. Physically active participants had fewer falls and significantly higher physical function compared with sedentary subjects, regardless of recent falls. Significant interactions for physical activity were found in the relationships of usual gait speed and SPPB with recent fall history (p for interaction terms <0.01). A difference in usual gait speed and SPPB according to history of recent falls was found only in physically active subjects.

CONCLUSIONS

Physical performance measures are negatively associated with recent falls in physically active, but not sedentary, participants. Physical activity is associated with better physical function, independently of recent fall history.

Diabetes mellitus, glycemic control, and incident depressive symptoms among 70- to 79-year-old persons: the health, aging, and body composition study

BACKGROUND

Cross-sectional studies find an elevated prevalence of depression among subjects with diabetes mellitus (DM). The causal mechanisms and temporal sequence of this association have not been clearly delineated. This study investigated the prospective relationship between DM and depressive symptoms.

METHODS

The Health, Aging, and Body Composition Study was a cohort study conducted in the metropolitan areas of Memphis, Tenn, and Pittsburgh, Pa. The analysis included 2522 community-dwelling subjects, aged 70 to 79 years, without baseline depressive symptoms. Incident depressed mood was defined as use of antidepressants at follow-up visits or presence of depressive symptoms (score >or=10 on the 10-item Center for Epidemiological Studies Depression scale). Presence of incident depressed mood at 2 consecutive annual clinic visits defined the incidence of recurrent depressed mood. Diabetes mellitus status, glycosylated hemoglobin (HbA1c) level, and DM-related comorbidities were assessed at baseline. Diabetes mellitus status was further characterized as absent, controlled (HbA1c level <7%), or uncontrolled (HbA1c level >or=7%). Discrete time survival analysis was used to estimate depressive events risk.

RESULTS

During a mean follow-up of 5.9 years, participants with DM had a higher age-, sex-, race-, and site-adjusted incidence of depressed mood (23.5% vs 19.0%) (P = .02) and recurrent depressed mood (8.8% vs 4.3%) (P<.001) than those without DM. Diabetes mellitus was associated with a 30% increased risk of incident depressed mood (odds ratio [OR], 1.31; 95% confidence interval [CI], 1.07-1.61), which was attenuated after adjustment for DM-related comorbidities (OR, 1.20; CI, 0.97-1.48). A stronger relationship was observed between DM and recurrent depressed mood (OR, 1.91; CI, 1.32-2.76), particularly among participants with poor glycemic control.

CONCLUSION

Among well-functioning older adults, DM is associated with increased risk of depressive symptoms.

Characteristics of nondisabled older patients developing new disability associated with medical illnesses and hospitalization

OBJECTIVE

To identify demographic, clinical, and biological characteristics of older nondisabled patients who develop new disability in basic activities of daily living (BADL) during medical illnesses requiring hospitalization.

DESIGN

Longitudinal observational study.

SETTING

Geriatric and Internal Medicine acute care units.

PARTICIPANTS

Data are from 1,686 patients aged 65 and older who independent in BADL 2 weeks before hospital admission, enrolled in the 1998 survey of the Italian Group of Pharmacoepidemiology in the Elderly Study.

MEASUREMENTS

Study outcome was new BADL disability at time of hospital discharge. Sociodemographic, functional status, and clinical characteristics were collected at hospital admission; acute and chronic conditions were classified according to the International Classification of Disease, ninth revision; fasting blood samples were obtained and processed with standard methods.

RESULTS

At the time of hospital discharge 113 patients (6.7%) presented new BADL disability. Functional decline was strongly related to patients' age and preadmission instrumental activities of daily living status. In a multivariate analysis, older age, nursing home residency, low body mass index, elevated erythrocyte sedimentation rate, acute stroke, high level of comorbidity expressed as Cumulative Illness Rating Scale score, polypharmacotherapy, cognitive decline, and history of fall in the previous year were independent and significant predictors of BADL disability.

CONCLUSION

Several factors might contribute to loss of physical independence in hospitalized older persons. Preexisting conditions associated with the frailty syndrome, including physical and cognitive function, comorbidity, body composition, and inflammatory markers, characterize patients at high risk of functional decline.

Association between anemia and physical disability in older patients: role of comorbidity

BACKGROUND AND AIMS

In older persons, anemia is a common medical disorder and is often associated with comorbidity and poor health outcomes. We evaluated the relationship between anemia and physical disability in a sample of older hospitalized patients, taking into account the role of comorbidity.

METHODS

Cross-sectional analysis of the baseline data of the Italian Group of Pharmacoepidemiology in the Elderly Study. Patients aged 65 years or older (n=10,903), admitted to participating centers in the 1993-1998 survey period, were included. Anemia was defined according to the World Health Organization (WHO) criteria; physical disability was defined as need for assistance in performing at least one Activity of Daily Living (ADL) in the week before admission. Comorbidity was ascertained using the Charlson Index.

RESULTS

Prevalence of anemia was 41.1%. In the unadjusted analysis, anemia was associated with increased likelihood of disability, in both women (Odds Ratio [OR]: 1.54; 95% Confidence Interval [CI]: 1.38-1.71) and men (OR 1.70; CI 1.52-1.90). After inclusion of demographics and life-style factors in multivariate analysis, the strength of association was only modestly attenuated, whereas nutritional factors and disease-related variables resulted in a greater reduction of the strength of association. In analyses stratified by comorbidity severity, the association between anemia and disability was statistically significant only in patients with the lowest comorbidity levels (p for anemia Charlson Index interaction term <0.05, in both women and men).

CONCLUSIONS

Among hospitalized subjects, anemia is associated with ADL disability. The disablement process associated with anemia may be partially explained by nutritional and disease-related factors. However, anemia appears to have an independent effect, particularly in subjects with low comorbidity.

Effects of a Physical Activity Intervention on Measures of Physical Performance: Results of the Lifestyle Interventions and Independence for Elders Pilot (LIFE-P) Study

BACKGROUND

The Short Physical Performance Battery (SPPB), which includes walking, balance, and chair stands tests, independently predicts mobility disability and activities of daily living disability. To date, however, there is no definitive evidence from randomized controlled trials that SPPB scores can be improved. Our objective was to assess the effect of a comprehensive physical activity (PA) intervention on the SPPB and other physical performance measures.

METHODS

A total of 424 sedentary persons at risk for disability (ages 70-89 years) were randomized to a moderate-intensity PA intervention or a successful aging (SA) health education intervention and were followed for an average of 1.2 years.

RESULTS

The mean baseline SPPB score on a scale of 0-12, with 12 corresponding to highest performance, was 7.5. At 6 and 12 months, the PA versus SA group adjusted SPPB (+/- standard error) scores were 8.7 +/- 0.1 versus 8.0 +/- 0.1, and 8.5 +/- 0.1 versus 7.9 +/- 0.2, respectively (p < .001). The 400-meter walking speed was also significantly improved in the PA group. The PA group had a lower incidence of major mobility disability defined as incapacity to complete a 400-meter walk (hazard ratio = 0.71, 95% confidence interval = 0.44-1.20).

CONCLUSIONS

A structured PA intervention improved the SPPB score and other measures of physical performance. An intervention that improves the SPPB performance may also offer benefit on more distal health outcomes, such as mobility disability.

Physical exercise and comorbidity. Results from the Fitness and Arthritis in Seniors Trial (FAST)

BACKGROUND AND AIMS

Physical exercise is associated with a lower risk of disability. The impact of comorbidity on the benefits from physical exercise has not been clearly investigated. Elders with comorbidity may benefit from physical exercise to preserve physical function.

METHODS

Data are from 435 participants with knee osteoarthritis aged > or = 60 years enrolled in the Fitness and Arthritis in Seniors Trial (FAST), who were randomly assigned to 18-month health educational (HE), weight training (WT), or aerobic exercise (AE) interventions. Comorbidity was defined as the presence of osteoarthritis and > or = 2 clinical conditions. Percent changes in the 6-minute walk test, self-reported disability and knee pain from baseline to 3-, 9-, and 18-month follow-up visits were analyzed according to comorbidity, using analysis of variance. Significances were adjusted using the Bonferroni method.

RESULTS

Mean age of the sample was 68.7 years. In participants with comorbidity (n=197), those in the AE intervention showed significant improvement in walking speed, compared to WT and HE groups, since the beginning of follow-up. Subjects with comorbidity in AE and WT groups showed improvement of the disability score at the 3-month follow-up visit compared to those in the HE group. This improvement was maintained at the end of the follow-up by the only AE group compared to the HE one (p=0.06). In participants with comorbidity, the pain score was improved by the AE intervention.

CONCLUSIONS

AE and WT interventions improve physical function in individuals with comorbidity. AE improves physical function and knee pain independently of the presence of comorbidity.

Anemia, Physical Disability, and Survival in Older Patients With Heart Failure

BACKGROUND

Anemia is common in congestive heart failure, and it has been associated with poor prognosis. The effect of anemia on functional ability in heart failure has not been described. We evaluated the relationship of anemia, physical disability, and survival in patients with heart failure.

METHODS AND RESULTS

One-year longitudinal study of 567 non-disabled, hospitalized heart failure patients, age > or = 65 years, enrolled in the Italian Group of Pharmacoepidemiology in the Elderly Study. Anemia was defined according to the World Health Organization criteria. Physical disability was defined as dependence in performing at least 2 basic activities of daily living. After adjustment for disease severity and health-related variables, anemia was associated with higher risk of disability (odds ratio = 2.17; 95% confidence interval [CI] = 1.12-4.24). After stratification according to gender, a strong relationship of anemia and risk of disability persisted in women, but it was reduced in men. Anemic women were significantly more likely to die during the follow-up, even after adjustment for potential confounders (hazard ratio = 2.33; CI = 1.02-5.30).

CONCLUSION

Anemia is a predictor of physical disability in older heart failure patients, and in women anemia is associated with increased mortality.

Impact of inflammation on the relationship among alcohol consumption, mortality, and cardiac events: the health, aging, and body composition study

BACKGROUND

Uncertainty remains about the overall survival benefit of alcohol consumption and the mechanisms underlying the cardioprotective effect of light to moderate alcohol intake. Recent evidence suggests an anti-inflammatory effect of light to moderate alcohol consumption. We investigated the relationship of alcohol intake with all-cause mortality and cardiac events and evaluated whether this relationship is mediated or modified by inflammatory markers.

METHODS

The analysis included 2487 subjects, aged 70 to 79 years, without baseline coronary heart disease (CHD) or heart failure (HF), participating in the Health, Aging, and Body Composition study. All-cause mortality and incident cardiac events (CHD and HF) were detected during a mean follow-up of 5.6 years. Alcohol consumption and serum levels of interleukin-6 (IL-6) and C-reactive protein (CRP) were assessed at baseline.

RESULTS

A total of 397 participants died, and 383 experienced an incident cardiac event. Compared with never or occasional drinkers, subjects drinking 1 to 7 drinks per week had lower age-, sex-, and race-adjusted incidences of death (27.4 vs 20.1 per 1000 person-years, respectively) and cardiac events (28.9 vs 20.8 per 1000 person-years). After adjustment for confounders, compared with never or occasional drinkers, light to moderate drinkers (1-7 drinks per week) showed a decreased risk of death (hazard ratio [HR], 0.75; 95% confidence interval [CI], 0.56-1.00) and cardiac events (HR, 0.72; CI, 0.54-0.97). Adjustment for potential mediators, and particularly inflammatory marker levels, did not affect the strength of this association.

CONCLUSION

Light to moderate alcohol consumption was associated with significantly lower rates of cardiac events and longer survival, independent of its anti-inflammatory effect.

Total Serum Cholesterol and Recovery From Disability Among Hospitalized Older Adults

BACKGROUND

The association between total serum cholesterol and health outcomes among older adults is controversial. The objective of the present study was to determine within a cohort of acutely hospitalized disabled elderly patients whether total cholesterol predicts recovery from disability in basic activities of daily living (ADL).

METHODS

Patients (3150) 65 years old or older admitted to 81 acute care units in Italy and presenting with ADL disability at hospital admission were included in this study. ADL disability was defined as need of assistance or total dependence in one or more ADLs (eating, dressing, personal hygiene, transferring, and toilet use). Recovery was defined as no disability at hospital discharge in any of the five ADLs considered.

RESULTS

Mean age of study participants was 80.5 +/- 7.2 years, and 1305 (41.1%) were men. The rate of recovery from ADL disability was 14.5% for participants with total cholesterol < 200 mg/dL (n = 306/2108), 20.2% for those with total cholesterol between 200 and 239 mg/dL (n = 144/713), and 23.1% for those with total cholesterol > or = 240 mg/dL (n = 76/329). After adjustment for potential confounders, relative to that of patients with cholesterol < 200 mg/dL, risk ratios for recovery were 1.31 for participants with cholesterol between 200 and 239 mg/dL (95% confidence interval [CI], 1.07-1.62) and 1.36 (95% CI, 1.04-1.79) for those with cholesterol > or = 240 mg/dL. After exclusion of 769 patients with total cholesterol < 145 mg/dL, the risk ratios (compared with those for participants with cholesterol < 200 mg/dL) for recovery were 1.33 (95% CI, 1.07-1.66) for participants with cholesterol between 200 and 239 mg/dL and 1.41 (95% CI, 1.06-1.88) for patients with cholesterol > or = 240 mg/dL.

CONCLUSIONS

Among hospitalized disabled older adults, elevated levels of cholesterol are associated with increased rate of recovery from ADL disability.

Anemia and recovery from disability in activities of daily living in hospitalized older persons

OBJECTIVES

To evaluate the predictive value of hemoglobin levels upon hospital admission on recovery from activity of daily living (ADL) disability during hospital stay in older patients.

DESIGN

Longitudinal observational study.

SETTING

Geriatric and internal medicine acute care units.

PARTICIPANTS

Data are from 5,675 patients aged 65 and older enrolled in the Italian Group of Pharmacoepidemiology in the Elderly Study with ADL disability upon hospital admission.

MEASUREMENTS

ADL disability was defined as inability to perform or need for assistance in performing one or more ADLs. Recovery from ADL disability was defined as independence in ADLs upon hospital discharge. Anemia was defined according to the World Health Organization criteria. Sociodemographic and clinical characteristics were considered as potential confounders.

RESULTS

Mean age was 80.5 years; 57.7% of subjects were female. Prevalence of anemia was 46.8%. A total of 536 (9.4%) participants regained independence in all six ADLs at hospital discharge. Patients with anemia had a lower rate of recovery from ADL disability than those with normal hemoglobin levels (7.0% vs 11.6%; P<.001). Adjusted analyses confirmed that anemia was inversely associated with the likelihood of ADL recovery (odds ratio=0.71, 95% confidence interval=0.57-0.88). The probability of ADL recovery in anemic patients was higher at higher hemoglobin concentrations.

CONCLUSION

In older hospitalized patients, anemia is inversely associated with the likelihood of regaining ADL independence during a hospital stay.

Anemia and cognitive performance in hospitalized older patients: results from the GIFA study

BACKGROUND

Anemia represents a major risk factor for adverse health-related events in older persons. The aim of this study was to evaluate the association between hemoglobin levels/anemia and cognitive function in hospitalized older persons.

METHOD

Data are from the Gruppo Italiano di Farmacovigilanza nell'Anziano (GIFA) study. Hemoglobin levels (in g/dL) were measured upon admission to hospital; anemia was defined according to the WHO criteria. Cognitive performance was assessed by the Abbreviated Mental Test (AMT) on admission; an AMT score <7 defined cognitive impairment. Logistic regressions and analyses of covariance were performed to evaluate the relationship between cognitive status and hemoglobin levels/anemia.

RESULTS

Mean age of the sample (n = 13,301) was 72.0 years. Participants with cognitive impairment presented a higher prevalence of anemia (47%) compared to those without cognitive impairment (35%, p < 0.001). Adjusted logistic regressions showed that hemoglobin levels/anemia were significantly associated with cognitive impairment (OR = 0.96, 95%CI = 0.94-0.99, p = 0.004, and OR = 1.32, 95%CI = 1.18-1.48, p < 0.001, respectively). Patients with anemia and cognitive impairment at the hospital admission presented a higher number of impaired Activities of Daily Living compared to those with only one or none of the studied conditions (p for trend < 0.001).

CONCLUSION

Low hemoglobin levels and anemia are independently associated with cognitive performance in older persons admitted to acute care units.

Frailty syndrome and skeletal muscle: results from the Invecchiare in Chianti study

BACKGROUND

Frailty is a common condition in elders and identifies a state of vulnerability for adverse health outcomes.

OBJECTIVE

Our objective was to provide a biological face validity to the well-established definition of frailty proposed by Fried et al.

DESIGN

Data are from the baseline evaluation of 923 participants aged > or =65 y enrolled in the Invecchiare in Chianti study. Frailty was defined by the presence of > or =3 of the following criteria: weight loss, exhaustion, low walking speed, low hand grip strength, and physical inactivity. Muscle density and the ratios of muscle area and fat area to total calf area were measured by using a peripheral quantitative computerized tomography (pQCT) scan. Analyses of covariance and logistic regressions were performed to evaluate the relations between frailty and pQCT measures.

RESULTS

The mean age (+/-SD) of the study sample was 74.8 +/- 6.8 y, and 81 participants (8.8%) had > or =3 frailty criteria. Participants with no frailty criteria had significantly higher muscle density (71.1 mg/cm(3), SE = 0.2) and muscle area (71.2%, SE = 0.4) than did frail participants (69.8 mg/cm(3), SE = 0.4; and 68.7%, SE = 1.1, respectively). Fat area was significantly higher in frail participants (22.0%, SE = 0.9) than in participants with no frailty criteria (20.3%, SE = 0.4). Physical inactivity and low walking speed were the frailty criteria that showed the strongest associations with pQCT measures.

CONCLUSION

Frail subjects, identified by an easy and inexpensive frailty score, have lower muscle density and muscle mass and higher fat mass than do nonfrail persons.

Executive function correlates with walking speed in older persons: the InCHIANTI study

OBJECTIVES

To study the association between performance on psychological tests of executive function and performance on lower extremity tasks with different attentional demands in a large sample of nondemented, older adults.

DESIGN

Cross-sectional study.

SETTING

Community-based.

PARTICIPANTS

Nine hundred twenty-six persons aged 65 and older, without dementia, stroke, parkinsonism, visual impairment, or current treatment with neuroleptics, enrolled in a large epidemiological study.

MEASUREMENTS

Trail Making Test (TMT) parts A and B and two performance-based measures of lower extremity function that require different executive/attentional-demanding skills: walking speed on a 4-m course at usual pace and walking speed on a 7-m obstacle course at fast pace. A difference score (Delta TMT), obtained by subtracting time to perform part A from time to perform part B of the TMT, was used as an indicator of executive function. Based on Delta TMT, subjects were divided into poor performance, intermediate performance, and good performance.

RESULTS

After adjustment, no association between Delta TMT and 4-m course usual-pace walking speed was found. Participants with poor Delta TMT and with intermediate Delta TMT performance were more likely to be in the lowest tertile for 7-m obstacle course walking speed.

CONCLUSION

In nondemented older persons, executive function is independently associated with tasks of lower extremity function that require high attentional demand.

Prescription of antithrombotic therapy in older patients hospitalized for transient ischemic attack and ischemic stroke: the GIFA study

BACKGROUND AND PURPOSE

Antithrombotic therapy has been demonstrated as an effective tool for secondary ischemic stroke prevention. Nevertheless, scant data are available on actual prescription of this therapy in clinical practice.

METHODS

A total of 17 337 patients admitted to geriatric and internal medicine wards participating in the study in the 1993 to 1998 survey period were analyzed. Patients with coded diagnoses of ischemic stroke and transient ischemic attack (TIA) were selected. Data recorded included demographic and clinical characteristics and medication prescription during hospital stay and at discharge. Logistic regression analyses were used to identify conditions associated with the prescription of antiplatelet or anticoagulant drugs.

RESULTS

Among 946 patients with diagnosis of stroke or TIA (mean age 78 years), >40% was discharged without antithrombotic prescription. Conditions that made the prescription more unlikely were diagnosis of stroke (odds ratio [OR]: 0.61; 95% confidence interval [CI]: 0.44 to 0.86), presence of anemia (OR: 0.70; 95% CI: 0.49 to 0.98), severe disability (OR: 0.48; 95% CI: 0.30 to 0.75), and cognitive impairment (OR: 0.58; 95% CI: 0.43 to 0.75). There was an independent and additive association of physical and cognitive status with antithrombotic therapy prescription.

CONCLUSIONS

A high rate of patients affected by stroke or TIA are discharged from the hospital without antithrombotic therapy. The most important correlates of the likelihood of not receiving an antithrombotic medication were cognitive and functional status.

Morning preference in onset of symptomatic third-degree atrioventricular heart block

The aim of this study was to examine 24h patterning in the symptoms indicative of third-degree atrio-ventricular (AV) heart block. We found a total of 227 cases (126 men and 101 women) of third-degree AV block that had been diagnosed by the Emergency Medical Department of the St. Anna Hospital in Ferrara, Italy between 1990 and 2001. Determination of the hour of onset of symptomatic third-degree AV block, however, was possible and listed in the records of only 161 or 70.9% of the cases (92 men and 69 women). The onset time of every event was categorized into one of four 6h spans of the 24h: night (00:00-05:59h), morning (06:00-11:59h), afternoon (12:00-17:59h), and evening (18:00-23:59h). The onset of the symptoms of third-degree AV block in the sample of 161 cases was significantly greater in the morning between 06:00 and 11:59h than any other 6h span of the day and night (chi2-test; p < 0.001). The same phenomenon was substantiated in the subgroup of the 92 males (chi2; p < 0.0001), although it could not be detected for the smaller subgroup of 69 women. The 24h pattern, with morning preference, in the onset of symptomatic third-degree AV block is similar to the one in sudden cardiac death and cardiogenic cardiac arrest. The etiology of the 24h pattern in symptomatic AV block is unknown; it may be an expression of intrinsic biological rhythmicity within the heart tissue or its control system, and/or the timing of environmental triggers resulting in coronary ischemia.