Health care for older people in Italy: The U.L.I.S.S.E. Project (Un link informatico sui servizi sanitari esistenti per l'anziano - a computerized network on health care services for older people)

OBJECTIVES

The U.L.I.S.S.E. study is aimed at describing older patients who are cared for in hospitals, home care or nursing homes in Italy.

DESIGN

The U.L.I.S.S.E. study is an observational multicenter prospective 1-year study.

SETTING

Overall, 23 acute geriatric or internal medicine hospital units, 11 home care services and 31 nursing homes participated in the study.

MEASUREMENTS

The patient's evaluation was performed using comprehensive geriatric assessment instruments, i.e. the interRAI Minimum Data Set, while data on service characteristics were recorded using ad-hoc designed questionnaires.

RESULTS

The older subjects who are in need of acute and long term care in Italy have similar characteristics: their mean age is higher than 80 years, they have a high level of disability in ADL, an important multimorbidity, and are treated with several drugs. The prevalence of cognitive impairment is particularly high in nursing homes, where almost 70% of residents suffer from it and 40% have severe cognitive impairment. On the other hand, there is a shortage of health care services, which are heterogeneous and fragmented.

CONCLUSIONS

Health care services for older people in Italy are currently inadequate to manage the complexity of the older patients. An important effort should be undertaken to create a more integrated health care system.

Subject classification obtained by cluster analysis and principal component analysis applied to flow cytometric data

BACKGROUND

Polychromatic flow cytometry (PFC) allows the simultaneous determination of multiple antigens in the same cell, resulting in the generation of a high number of subsets. As a consequence, data analysis is the main difficulty with this technology. Here we show the use of cluster analysis (CA) and principal component analyses (PCA) to simplify multicolor data visualization and to allow subjects' classification.

METHODS

By eight-colour cytofluorimetric analysis, we investigated the T cell compartment in donors of different age (young, middle-aged, and centenarians). T cell subsets were identified by combining positive and negative expression of antigens. The resulting data set was organized into a matrix and subjected to CA and PCA.

RESULTS

CA clustered people of different ages on the basis of cytofluorimetric profile. PCA of the cellular subsets identified centenarians within a different cluster from young donors, while middle-aged donors were scattered between these groups. These approaches identified T cell phenotypes that changed with increasing age. In young donors, memory T cell subsets tended to be CD127+ and CD95- whereas CD127-, CD95+ phenotypes were found at higher frequencies in people with advanced age.

CONCLUSIONS

Our data suggest the use of bioinformatic approaches to analyze large data-sets generated by PFC and to obtain the rapid identification of key populations that best characterize a group of subjects.

A Retrospective Study on Heat-Related Mortality in an Elderly Population During the 2003 Heat Wave in Modena, Italy: The Argento Project

BACKGROUND

Summer 2003 witnessed an excess in heat-related mortality in the elderly population. The Argento Project was planned to define risk factors for heat-related death in Modena, Italy, during the hottest month of 2003 (August).

METHODS

We performed a retrospective, case-control study of a cohort of 394 older persons living in Modena, 197 dead (cases) and 197 survivors (controls). A questionnaire to collect information about demographic, social, environmental, and clinical characteristics and about causes of death was completed.

RESULTS

Cases were more likely to be living in a nursing home and needing assistance (p =.024, and p <.001, respectively). Survivors were living on higher level floors (p =.046). Spending the summer in Modena was significantly related to poor outcomes (p <.01). A higher number of cases were using public health services (p <.001). Individuals who died had a greater degree of comorbidity and dependence (p <.001); they were cognitively impaired (p <.001), took a larger number of drugs (p <.001), and had a greater number of hospital admissions (p <.001). Multivariate analysis showed that patients who spent the summer in Modena had a higher mortality. Other predictors of death were the use of home public-integrated assistance, a higher comorbidity and a higher degree of disability; the loss of at least 1 Activity of Daily Living (ADL) represents the strongest risk factor of heat-related death.

CONCLUSIONS

Our study identifies the major risk factors of heat-related death in the elderly population. With the creation of an up-to-date database, when a new heat wave will come, it will be possible to identify frail persons for preventive targeted strategies.

Diagnosis and characteristics of syncope in older patients referred to geriatric departments

OBJECTIVES

To test the applicability and safety of a standardized diagnostic algorithm in geriatric departments and to define the prevalence of different causes of syncope in older patients.

DESIGN

Multicenter cross-sectional observational study.

SETTING

In-hospital geriatric acute care departments and outpatient clinics.

PARTICIPANTS

Two hundred forty-two patients (aged>or=65, mean+/-standard deviation=79+/-7, range 65-98) consecutively referred for evaluation of transient loss of consciousness to any of six clinical centers participating in the study. Of these, 11 had a syncope-like condition (5 transient ischemic attack; 6 seizures), and 231 had syncope (aged 65-74, n=71; aged>or=75, n=160).

MEASUREMENTS

Protocol designed to define etiology and clinical characteristics of syncope derived from European Society of Cardiology Guidelines on syncope.

RESULTS

No major complication occurred with use of the protocol. Neurally mediated was the more prevalent form of syncope in this population (66.6%). Cardiac causes accounted for 14.7% of all cases. The neuroreflex form of syncope (vasovagal, situational, and carotid sinus syndrome) was more common in younger than in older patients (62.3% vs 36.2%; P=.001), whereas orthostatic syncope was more frequent in the older than in the younger group (30.5% vs 4.2%; P<.001). In only 10.4% of cases, syncope remained of unexplained origin. After initial evaluation, a definite diagnosis was possible in 40.1% of the cases, and a suspected diagnosis was obtained in 57.9%. Syncope of suspected cardiac origin after initial evaluation was confirmed in 43.7% of cases, and neuromediated causes were confirmed in 83.5% of the cases.

CONCLUSION

The protocol is applicable even beyond the age of 90 in geriatric departments. The standardized protocol is associated with a reduction in the frequency of unexplained syncope to about 10%.

Thymic output and functionality of the IL-7/IL-7 receptor system in centenarians: implications for the neolymphogenesis at the limit of human life

During aging, the thymus undergoes a marked involution that is responsible for profound changes in the T-cell compartment. To investigate the capacity of the thymus to produce new cells at the limit of human lifespan, we analyzed some basic mechanisms responsible for the renewal and maintenance of peripheral T lymphocytes in 44 centenarians. Thymic functionality was analyzed by the quantification of cells presenting the T-cell receptor rearrangement excision circles (TREC). A new method based upon real-time PCR was used, and we found that most centenarians (84%) had undetectable levels of TREC+ cells. Six-color cytofluorimetric analysis revealed that centenarians had an extremely low number of naïve T cells; central memory and effector memory T cells were greatly increased, while terminally differentiated cells were as numerous as in young (aged 20-45) or middle-aged (aged 58-62) donors. Interleukin (IL)-7 and IL-7 receptor alpha-chain (CD127) levels were the same at all ages, as shown by ELISA, flow cytometry and real-time PCR. However, IL-7 plasma levels were higher in centenarian females than males. The presence of TREC+ cells and of very few naïve T lymphocytes suggests that in centenarians such cells could either derive from residues of thymic lymphopoietic islets, or even represent long-living lymphocytes that have not yet encountered their antigen. IL-7 could be one of the components responsible, among others, for the higher probability of reaching extreme ages typical of females.

A role for homocysteine increase in haemolysis of megaloblastic anaemias due to vitamin B12 and folate deficiency: results from an in vitro experience

Megaloblastic anaemias (MA) are frequently associated with haemolysis. The pathogenesis of these finding is not clear, but it is thought to depend on the greater destruction of abnormal and fragile megaloblastic erythrocytes. Vitamin B(12) and folate deficiencies are the commonest cause of MA; these deficiencies may simultaneously induce a significant alteration in homocysteine metabolism leading to hyperhomocysteinemia. Blood cells have enzymes involved in homocysteine metabolism. Considering the possible effects of hyperhomocysteinemia in erythrocyte toxicity (due to oxidative damage and/or to interaction with sulfhydryl residues of structural and enzymatic proteins), the aim of our study was to evaluate (1) the homocysteine blood cells production in patients with MA due to vitamin B(12) and folate deficiency and (2) the possible role and mechanism of hyperhomocysteinemia in MA haemolysis. After incubation at 37 degrees C, blood samples from MA patients showed higher and significant levels of Hcy, LDH, lipid peroxidation parameters (MDA), and ghost protein-bound Hcy than controls. Haemolysis (%) was higher in MA patients than controls and was significantly correlated with Hcy accumulation in the medium, lipid peroxidation indices and ghost protein-bound Hcy. No significant (or significantly lower) alterations through time in considered parameters were observed in the corresponding samples incubated at 4 degrees C or in samples incubated with methionine-free medium (lower Hcy production). Our data, deriving from an in vitro experience, suggest a possible role of Hcy accumulation due to vitamin B(12) and folate deficiencies in haemolysis associated to MA due to vitamin deficiency.

Balanced Regulation of mRNA Production for Fas and Fas Ligand in Lymphocytes From Centenarians

Background— The functionality of the immune system during aging is crucial for protection against the most common age-related diseases. Apoptosis plays a central role in the senescence of the immune system, as evidenced by the increased plasma membrane expression of a key molecule like Fas protein. We analyzed the mRNA levels of different forms of Fas (total [tFas] and membrane [mFas]) and of its ligand (FasL) in peripheral blood lymphocytes from centenarians, the best example of successful aging, who were compared with young and middle-aged donors.

Methods and Results— Using real-time polymerase chain reaction, we quantified mRNA for different forms of Fas and for FasL. In resting lymphocytes, mRNA for tFas, but not for mFas, significantly increases with age, whereas FasL mRNA significantly decreases. In vitro production of Fas/FasL mRNA after different stimuli was similar in cells from the 3 groups. Even if the percentage of Fas + cells was higher than in the other groups, peripheral blood lymphocytes from centenarians had normal Fas-induced apoptosis, as revealed by flow cytometry. By ELISA, we observed that cells from centenarians showed normal in vitro production of the soluble form of Fas (sFas) and that plasma levels of such molecule were significantly higher in centenarians than in the other groups.

Conclusions— Lymphocytes from centenarians are able to balance the production of proapoptotic (mFas and FasL) and antiapoptotic (sFas) molecules, whose proportions are likely crucial for the well-preserved immune functionality at the extreme limits of human life.

Plasma homocysteine after insulin infusion in type II diabetic patients with and without methionine intolerance

BACKGROUND

A high prevalence of hyperhomocysteinemia has been reported in type II diabetic patients with documented vascular disease; hence the hypothesis that hyperhomocysteinemia may contribute to overall mortality in diabetic patients. The link between insulin and homocysteine metabolism has not been completely clarified yet; in particular, only few data are available on the effects of insulin in vivo on homocysteine metabolism in the presence of abnormalities of sulphur amino acid metabolism (methionine intolerance).

MATERIALS AND METHODS

To establish whether methionine intolerance and which of its determinants could influence total plasma homocysteine in response to insulin infusion in vivo in type II diabetic patients, we submitted 18 patients (Group A) with normal and 18 patients with abnormal (hyperhomocysteinemia) (Group B) response to oral methionine load to a glucose/clamp study. At time 0, and 30, 60 and 120 minutes after hyperinsulinemia, homocysteine and methionine plasma levels were assessed. In order to evaluate the cause of methionine intolerance, all patients were assayed for fasting homocysteine-cysteine ratio (as a marker of suspected heterozygosis for cystathionine-beta-synthase deficit), MTHFR C (677)T status and homocysteine-related vitamin status (serum vitamin B (6) [PLP], vitamin B (12) and folate).

RESULTS

After hyperinsulinemia, plasma methionine was reduced (by about - 30 % at 120 minutes vs. basal values) within both groups, whereas tHcy tend to decrease in group A following insulin administration (up to - 6.6 +/- 3.6 % vs. basal values at 120 minutes) with a significantly higher variability, while in patients with "methionine intolerance" (group B) tHcy tended to increase (up to + 29.05 +/- 8.3 % vs. basal values at 120 min from the clamp). Serum folic acid (7.45 +/- 2.8 vs. 4.82 +/- 2.5 nmol/L, p < 0.05), Vit. B (12) (348 +/- 78 vs. 242 +/- 65 pmol/L, p < 0.05) and PLP (84.1 +/- 23.6 vs. 50.6 +/- 32.4 nmol/L; p < 0.01) were significantly higher in group A than in group B; PLP levels significantly correlated with homocysteine after 4 h methionine load (n = 36; r = - 0.327, p < 0.05); group A showed also a significantly lower prevalence of suspected heterozygosis for cystathionine-beta-synthase deficit (1/18 [11.1 %] vs. 5/18 [33.3 %], p < 0.05) and MTHFR T allele presence (4/18 [22.2 %] vs. 11/18 [61.1 %], p < 0.01). A stepwise regression analysis with tHcy plasma level variations (event A = reduction; event B = increase) as the dependent variable showed that low serum folate and PLP levels and presence of MTHFR T allele were the variables associated with insulin-induced tHcy increase.

CONCLUSIONS

Methionine intolerance may influence the effect of insulin administration on plasma homocysteine in patients affected by type 2 diabetes. To prevent a possible acute (and repeated) hyperhomocysteinemia due to insulin administration in cases of methionine intolerance, it may be useful to assess the presence of methionine intolerance (tHcy after oral methionine loading) and Hcy-related vitamin status in all patients due to be subjected to insulin therapy.

Red wine consumption prevents vascular oxidative stress induced by a high-fat meal in healthy volunteers

In order to investigate the effect of red wine on plasma lipid and oxidative stress parameters after a high-fat meal, fifteen healthy volunteers were studied: three days after a high-fat meal with 250 mL of water, they received the same meal with 250 mL of red wine. During both periods, serial blood samples were drawn before and 2, 4, and 8 hours after the meal to evaluate plasma lipids (cholesterol and triglycerides; retinyl palmitate), oxidative stress (D-ROM, and malondialdehyde) and antioxidant (total plasma antioxidant levels and uric acid) parameters. During the meal without wine, plasma lipid parameters increased significantly, whereas plasma total plasma antioxidant levels decreased, and a trend toward reduction of uric acid levels was seen). A similar trend in lipid parameters was observed after the meal with wine; no significant difference in individual lipid parameter trends after a meal with and without wine was observed. Wine ingestion induced higher total plasma antioxidant levels and uric acid; malondialdehyde levels remained constant after wine ingestion. Plasma D-ROM showed a significant postprandial increase in both experiments, but it was significantly lowered after wine ingestion. Our results give evidence of oxidative stress following a fat-rich meal in healthy subjects, suggesting that ingestion of red wine during a high-fat meal significantly reduces oxidative stress without inducing any significant modification in postprandial lipemia.

The “Nondipper” Elderly: A Clinical Entity or a Bias?

OBJECTIVES

To determine the prevalence of nondipper (ND) blood pressure profile in the elderly and to ascertain whether the ND pattern of ambulatory blood pressure in the elderly is an artifact or represents a specific clinical entity.

DESIGN

Cross-sectional, observational study.

SETTING

Cardiovascular diagnostic center, division of geriatrics, secondary care, institutional practice.

PARTICIPANTS

Sixty-five consecutive community-dwelling elderly hypertensive patients referred to the cardiovascular center.

MEASUREMENTS

The patients underwent actigraphy and ambulatory blood pressure monitoring and completed a sleep assessment questionnaire. Patients were divided based on the night-time decrease in blood pressure (>10%: "dippers" (n=19); <10%: "NDs" (n=46)).

RESULTS

Nondippers displayed poorer quality of sleep, as demonstrated objectively by actigraphic data; they obtained a higher mean score+/-standard deviation on the sleep questionnaire (4.6+/-2.9 vs 3.0+/-1.1, P=.030) and were taking more benzodiazepines (33.1% vs 10.7%, P=.035), indicating that their usual sleep quality was worse than that of dippers. Multivariate analysis showed a strong correlation between nondipper profile and quality of sleep and also with comorbidity, total number of drugs being taken, and pulse pressure.

CONCLUSION

Actigraphy demonstrates impaired sleep in the nondipper elderly. Nevertheless, the nondipping pattern seems independent of the discomfort of cuff-inflation during the night and occurs in association with higher comorbidity and polypharmacy; therefore, it cannot be considered a "bias," but is related to detrimental clinical conditions that should be studied in depth.

Snoring, hypertension and Type 2 diabetes in obesity. Protection by physical activity

Sleep-related breathing disorders are recognized as major health problems in obesity. They are involved in both hypertension and Type 2 diabetes, through mechanisms possibly related to increased sympathetic tone. We studied the association of habitual snoring with diabetes, hypertension, weight cycling and physical activity in a large Italian database of treatment-seeking obese subjects. Clinical and behavioral data were assessed by standardized questionnaires. Consecutive data of 1890 obese patients were analyzed [average body mass index (BMI), 38.2 kg/m2, median age: 46 yr, 78% females], from 25 obesity Italian centers, with low prevalence of clinical manifestations of cardiovascular disease. Habitual snoring was reported in 56% of the cases, and was associated with day-time sleepiness. The prevalence increased with obesity class and waist circumference, and was positively associated with weight cycling and weight gain since the age of 20, and smoking. Regular physical activity had a protective effect. Snoring was associated with diabetes and hypertension at univariate analysis, but in multivariate analysis an independent effect was only observed for hypertension. After adjustment for age, gender and BMI, physical activity maintained an independent, protective effect on both snoring (odds ratio 0.65, 95% confidence interval 0.49-0.84; p=0.001), diabetes (0.50, 0.30-0.86; p=0.011) and hypertension (0.71, 0.53-0.95; p=0.023). We conclude that in treatment-seeking, obese subjects with low prevalence of cardiovascular disease, snoring independently increases the risk of hypertension, whereas physical activity exerts a protection on both snoring and complications. These data underline the importance of lifestyle interventions to limit the burden of obesity and associated diseases.

Hyperhomocysteinemia and Other Newly Recognized Inherited Coagulation Disorders (Factor V Leiden and Prothrombin Gene Mutation) in Patients with Idiopathic Cerebral Vein Thrombosis

BACKGROUND

Idiopathic cerebral vein thrombosis (iCVT) represents approximately 30% of the cases of cerebral vein thrombosis (CVT). New, inherited - factor V Leiden (FVL) and prothrombin gene mutation (PTHRA20210) - and inherited/acquired - hyperhomocysteinemia (HHcy) - prothrombotic conditions have been detected recently.

METHODS

We assessed fasting plasma homocysteine (Hcy) levels and main Hcy determinants, FVL and PTHRA(20210) in 30 patients with documented iCVT and 40 age- and sex-matched healthy subjects.

RESULTS

A strong and significant association of PTHRA(20210) [30% (9/30) vs. 2.5% (1/40) iCVT vs. controls, respectively, p = 0.001; OR = 16.174, p = 0.002] and HHcy [13/30 (43.3%) vs. 4/40 (10%) iCVT vs. controls, respectively; p = 0.002, OR = 6.88, p = 0.002] with iCVT was found.

CONCLUSIONS

PTHRA(20210) and HHcy should be considered when screening for thrombophilia and should be assessed in patients with a family or personal history of CVT.

The MALVA (MAntova LongeVA) study: an investigation on people 98 years of age and over in a province of Northern Italy

The MALVA (MAntova LongeVA) study aims at investigating the socio-demographic, clinical and genetic characteristics of all subjects over 98 years of age residing in the province of Mantova (Northern Italy). In this paper we present the study protocol and the main demographic results. Absolute number, prevalence ratio and female/male ratio of the subjects aged 98+ and of the centenarians in the Mantova province (370,645 inhabitants at 31st December 1997) were checked at the baseline of the study (31st March 1998) as well as in the two years preceding and following the study. A total of 117 subjects aged 98+ (including 39 centenarians) were traced at 31st March 1998; the prevalence ratio was 31.6 per 100000 (12.1 for centenarians), and the female/male ratio was 6.3 (6.5 for centenarians). The distribution of the oldest old according to places of birth and residence was non-homogeneous across the provincial territory. Seventy-seven subjects (66% of the identified subjects) were enrolled in the study and administered a protocol including an interview about socio-economic conditions, lifetime habits and pathological and pharmacological case histories, as well as medical examination, performance-based tests and blood sample collection. Data on the socio-demographic characteristics and the health status of very old people in the province of Mantova are discussed and compared to findings from previous studies on Italian centenarians.

Relevance of different apolipoprotein content in binding of homocysteine to plasma lipoproteins

BACKGROUND AND AIMS

In plasma the atherogenic thiol homocysteine (Hcy) circulates either free or bound to proteins (Pb-Hcy). The present study sets out to evaluate the lipoprotein-Hcy (LP-Hcy) binding in vivo and the possible influence of different apolipoprotein content in this binding, being lipoprotein oxidation a possible mechanism of Hcy-induced damage.

METHODS AND RESULTS

In 34 healthy subjects we assayed fasting plasma lipoprotein and correspondent apolipoprotein (apo A-I, apo A-II, apo C-II, apo C-III, apo B, apo(a) and apo E content, and Hcy bound to different plasma protein fractions; moreover ten subjects underwent an oral methionine load in order to evaluate possible "dynamic" modifications of Pb-Hcy and LP-Hcy after induction of hyperhomocysteinemia. Pb-Hcy (mean values 9.22 +/- 1.7 mumol/L) represented about 78% of total plasma Hcy (mean values 11.8 +/- 1.8 mumol/L). Pb-Hcy distribution between the different fractions was as follows (mumol/L): VLDL = 0.25 +/- 0.08 (2.7%); LDL = 0.88 +/- 0.22 (9.5%); HDL = 1.40 +/- 0.36 (15.2%); fractions with density greater than 1.21 g/mL (Lipoprotein-Free Protein Fraction, LPDS) = 6.7 +/- 1.2 (72.6%). Hcy/protein ratios (nmol/mg of protein) in each protein fraction were: VLDL = 0.32 +/- 0.19, LDL = 0.43 +/- 0.37, HDL = 0.26 +/- 0.18, LPDS < 0.1, thus suggesting a higher binding capacity for Hcy by VLDL and LDL. These data were confirmed by the higher increase in Hcy content in LDL and VLDL (76 and 90%, respectively vs 36% and 3.1% for HDL and LPDS fractions) after hyperhomocysteinemia. Lp-Hcy binding significantly correlated with the apo B content of VLDL and LDL and Apo A-I content of HDL.

CONCLUSIONS

An important fraction of plasma Hcy circulates bound to LP (about 27% of Pb-Hcy); VLDL and LDL show the highest binding capacity for Hcy, probably due to their content in Apo B, a possible high capacity binding site for Hcy.

Cross-calibration of eight-polar bioelectrical impedance analysis versus dual-energy X-ray absorptiometry for the assessment of total and appendicular body composition in healthy subjects aged 21-82 years

AIM

To calibrate eight-polar bioelectrical impedance analysis (BIA) against dual-energy X-ray absorptiometry (DXA) for the assessment of total and appendicular body composition in healthy adults.

RESEARCH DESIGN

A cross-sectional study was carried out.

SUBJECTS

Sixty-eight females and 42 males aged 21-82 years participated in the study.

METHODS

Whole-body fat-free mass (FFM) and appendicular lean tissue mass (LTM) were measured by DXA; resistance (R) of arms, trunk and legs was measured by eight-polar BIA at frequencies of 5, 50, 250 and 500 kHz; whole-body resistance was calculated as the sum R of arms, trunk and legs.

RESULTS

The resistance index (RI), i.e. the height(2)/resistance ratio, was the best predictor of FFM and appendicular LTM. As compared with weight (Wt), RI at 500 kHz explained 35% more variance of FFM (vs 0.57), 45% more variance of LTM(arm) (vs 0.48) and 36% more variance of LTM(leg) (vs 0.50) (p < 0.0001 for all). The contribution of age to the unexplained variance of FFM and appendicular LTM was nil or negligible and the RI x sex interactions were either not significant or not important on practical grounds. The percent root mean square error of the estimate was 6% for FFM and 8% for LTM(arm) and LTM(leg).

CONCLUSION

Eight-polar BIA offers accurate estimates of total and appendicular body composition. The attractive hypothesis that eight-polar BIA is influenced minimally by age and sex should be tested on larger samples including younger individuals.

Urinary and plasma homocysteine and cysteine levels during prolonged oral N-acetylcysteine therapy

Acute administration of N-acetylcysteine (NAC) may induce alterations in plasma and urinary levels of homocysteine (Hcy) and cysteine (Cys). We studied the effects of continuous oral NAC therapy on different Hcy and Cys plasma and urinary forms in 40 healthy subjects assigned to three groups (groups A: n = 13, no therapy; group B: n = 14, NAC 600 mg/day, and group C: n = 14, NAC 1,800 mg/day) for 1 month (T(1)). After a 1-month washout period without therapy (T(2)), all subjects were treated with oral NAC (1,800 mg/day) for 2 months and (T(3) and T(4)) reassessed monthly for plasma and urinary thiols. The treated subjects showed a significant decrease in plasma total Hcy and a slight increase in total Cys levels; the alterations of different forms of plasma thiols suggested an NAC-induced increase in disulfide forms and an increase in urinary Hcy and Cys excretion as disulfide forms. The effects appeared to be dose dependent, being more marked in subjects treated with higher dosages. This approach may be important, as an association or alternative therapy in hyperhomocysteinemic conditions of poor responses to vitamins.

Development of real time PCR assays for the quantification of Fas and FasL mRNA levels in lymphocytes: studies on centenarians

Apoptosis plays a central role in the homeostasis of the immune system. During aging, there is an altered regulation of pivotal molecules that are responsible for the regulation of this type of cell death, such as those of the Fas/FasL system. Understanding the regulation of these genes can help to clarify, at least in part, the age-related changes that occur in immune cells. We have developed an original real time PCR assay for quantification of mRNA for Fas and FasL, and have studied a group of young donors, middle aged subjects and centenarians. We have found that the production of Fas mRNA is greatly increased in resting lymphocytes from centenarians; such an increase follows an age-related trend. On the contrary, the production of mRNA for the molecule, which is the natural ligand of Fas, i.e. FasL, is consistently reduced. Our preliminary results suggest that during aging a subtle balance in the production of molecules that cause apoptosis could exist, and that, in order to avoid an excessive death of immune cells, a still unknown mechanism could compensate the increase of Fas with the reduction of FasL.

The "time and change" test: an appropriate method to detect cognitive decline in the elderly

The Time and Change (T&C) test is an easy and time-saving test validated for the detection of dementia. Our aim was to determine how geriatric features like depression, disability, and comorbidity are able to influence the result of the T&C and, consequently, to decide whether it could be a reliable screening test for cognitive impairment in the elderly. A total of 220 participants (mean age = 75.8+/-9.6 years, 63.7% females) underwent the T&C, Mini-Mental State Examination, and the Clock Drawing Test; Activities of Daily Living, Instrumental Activities of Daily Living, comorbidity, and depression were also evaluated. Time and Change-positive participants were older, had poorer cognitive tests, and had higher levels of disability and comorbidity than participants testing negative. Multivariate analysis showed that cognitive impairment and comorbidity were the only features that influenced the T&C, regardless of age, education, disability, and depression. We conclude that the T&C should be implemented in primary care because it quickly identifies elderly patients with cognitive impairment who need a more accurate evaluation.

Relationship between body composition and bone mineral content in young and elderly women

PRIMARY OBJECTIVE

To study the relationship between bone mineral content (BMC), lean tissue mass (LTM) and fat mass (FM) in a large sample of young and elderly women.

RESEARCH DESIGN

Cross-sectional.

METHODS AND PROCEDURES

BMC, LTM and FM were measured by dual-energy X-ray absorptiometry in 2009 free-dwelling Caucasian women aged 63 +/- 7 years (mean +/- SD; range: 37-88 years). The majority of women were postmenopausal (96%).

RESULTS

LTM explained 13% more variance of BMC than FM (R(2)(adj) = 0.39 vs 0.26, p < 0.0001) but weight (Wt) explained 5% more variance of BMC than LTM (R(2)(adj) = 0.44, p < 0.0001). The prediction of BMC obtained from LTM and FM (R(2)(adj)= 0.46, p < 0.0001) was only slightly better than that obtained from Wt. After the effects of age, Wt and height (Ht) on BMC were taken into account by multiple regression, the contribution of LTM and FM to BMC was just one-fifth of that of Wt (R(2)(adj) for full models < or =0.56, p < 0.0001). After a further correction for bone area (BA), the contribution of LTM and FM to BMC was just one-tenth of that of BA and not different from that of Wt and Ht on practical grounds (R(2)(adj) for full models = 0.84, p < 0.0001). Thus, after inter-individual differences in age, Wt, Ht (and bone size) are taken into account, the relationship between body composition and BMC is substantially weakened.

CONCLUSIONS

In Caucasian women, (1) LTM is a stronger predictor of BMC than FM, but (2) Wt is a better predictor of BMC than body composition for practical purposes, and (3) Wt and body composition are not able to explain more than 46% of BMC variance.

Genetic polymorphisms of Fas (CD95) and FasL (CD178) in human longevity: studies on centenarians

Apoptosis plays a crucial role in immunosenescence, as also evidenced by the increased expression of Fas in lymphocytes from aged people. However, little is known about the genetic regulation of Fas and its ligand, FasL. We have studied their polymorphisms in 50 centenarians and 86 young donors living in Northern Italy. The first Fas polymorphism, at position -670, has in Caucasian a heterozigosity of 51%; the second, at -1377 position, has the wild type allele (G) with a very high frequency (83%) respect to the mutant allele. Genotype and allele distribution for both polymorphisms were similar in controls and centenarians. Similar results were found as far as two FasL polymorphisms (IVS2nt-124 and IVS3nt169) are concerned. On the whole, our data suggest that Fas and FasL polymorphisms, as well as their haplotypes, are unlikely to be associated with successful human longevity.

Impact factor of medical journals: problems in geriatrics

The Impact Factor (IF) is one of the most reliable methods for evaluating the quality of scientific journals. To date, no one has studied the IF of geriatric journals over time. Our aims were 1) to evaluate the IF trend of geriatric journals in general, and with respect to internal medicine, which is the nearest discipline, and 2) to assess the proportion of papers on common geriatric topics published in geriatric journals, with respect to other general periodicals. The current literature was studied to define what IF is and describe its good points and deficiencies. We then analyzed the situation regarding geriatric journals. A bibliometric analysis addressed the kind of journal interested in important geriatric themes (syncope, falls, hip fractures, delirium). Geriatric journals have a low IF, but their importance has been growing over the years. Despite this, papers regarding geriatric themes are published mainly in non-specific journals, and the number of publications regarding syncope, falls, hip fractures, and delirium has not increased during the period in question. In conclusion, it is difficult to use the IF for comparisons between different disciplines, in particular when the one under consideration (geriatrics and gerontology) is spread over a wide range of medical fields. The increase in IF of geriatric journals over time is the most important result of our analysis; this finding will encourage geriatric scientists to submit their papers to geriatric periodicals and will increase the specificity of the gerontological discipline.

Hyperhomocysteinemia and related factors in 600 hospitalized elderly subjects

Hyperhomocysteinemia (HHcy) is a metabolic disorder frequently occurring in the elderly population. Recently several reports have suggested abnormalities in homocysteine (tHcy) metabolism implicating HHcy as a metabolic link in the multifactorial processes characterizing many geriatric illnesses-with special emphasis on atherosclerotic vascular diseases and cognitive impairment. The present study was undertaken in a large sample of elderly hospitalized subjects to determine (1) the prevalence of HHcy, (2) the association of HHcy with vascular and cognitive disorders, and (3) the factors independently predicting Hhcy. Six hundred elderly subjects (264 men and 336 women; mean age, 79 +/- 9 years) were randomly chosen from those admitted as inpatients over a period of 3 years. In all patients, body mass index (BMI), mid-upper arm muscle area (MUAMA), plasma cholesterol, triglycerides, total proteins, albumin, lymphocyte count, creatinine, homocysteine (fasting and 4 hours after methionine oral load), serum vitamin B(6), vitamin B(12), and folate concentrations were measured. The presence of disease or use of medications known to affect homocysteine plasma levels were also recorded. The mean fasting tHcy level was 16.8 +/- 12 micromol/L in the whole sample, 18.18 +/- 13.25 micromol/L in men, and 15.86 +/- 12.14 micromol/L in women (P =.005 men v women). The mean Hcy level 4 hours after methionine load was 37.95 +/- 20.9 in the whole sample. Prevalence of hyperhomocysteinemia (fasting Hcy > or = 15 micromol/L or 4 hours after methionine load > or = 35 micromol/L) was 61% (365/600) (67% in men and 56% in women, P <.05). HHcy was rarely (8%) an isolated disorder; in addition to diabetes (20%), renal failure (48.2%), and malnutrition (20.2%), it was often associated with heart failure (30%), malignancies (20.5%), and the use of diuretics (56%) and anticonvulsant drugs (13%). Plasma homocysteine progressively increases across subjects from those with no diabetes, malnutrition, renal failure, obesity, inflammatory bowel disease, heart failure to those with 1, 2, or more concurrent diseases. Multiple stepwise regression analysis showed that 72% of plasma total fasting tHcy variability was explained by age, serum folate, plasma albumin, use of diuretics, and renal function (measured as plasma creatinine clearance). In conclusion, the present study documents that hyperhomocysteinemia, in elderly hospitalized patients is (1) a common finding, (2) frequently associated with vascular and cognitive disorders, and (3) probably a secondary phenomenon in most cases. The major predictor of high plasma homocysteine levels were age, serum folate, plasma albumin, plasma creatinine clearance, and use of diuretic drugs. These variables explain a large proportion of plasma Hcy variability.

Continuous combined hormone replacement therapy with oral 17beta-estradiol and norethisterone acetate improves homocysteine metabolism in postmenopausal women

OBJECTIVE

To evaluate the effect of a continuous combined oral hormone replacement therapy (HRT) on basal and post-methionine load homocysteine levels in postmenopausal women.

DESIGN

Twenty-two postmenopausal women (PMW) were randomly allocated to receive either continuous combined oral HRT (2 mg of estradiol plus 1 mg of norethisterone acetate; n = 11) or no treatment (controls, n = 11) for 6 months. A methionine oral load (0.1 g/kg body weight) was performed in each subject at time 0 and after 6 months. Serum homocysteine levels were measured by high-performance liquid chromatography in samples collected at time 0 and at 4, 8, and 24 h after the methionine load, while levels of vitamin B6 (by high-performance liquid chromatography) and B12 and folate (both by ELISA) were assayed in samples collected at time 0.

RESULTS

Serum levels of glucose and body mass index increased in treated PMW, whereas folate decreased in controls. In treated PMW, basal homocysteine tended to decrease (10.6 +/- 3.3 micromol/L vs. 9.62 +/- 2.8 micromol/L, p = 0.062), whereas in controls it significantly increased (10.7 +/- 2.65 micromol/L vs. 12.17 +/- 3.89 micromol/L, p < 0.05). This increase was not significant after correction for vitamin status (p = 0.072). Homocysteine values 4 h (31.9 +/- 13.53 micromol/L vs. 39.83 +/- 22.53 micromol/L, p < 0.05) and 8 h (35.1 +/- 13.13 vs. 43.34 +/- 22.15 micromol/L) after methionine, and integrated homocysteine response to methionine (392.5 +/- 133.8 micromol/24 h vs. 458.8 +/- 104.8 micromol/24 h; p < 0.05), were significantly reduced in HRT-treated, but not in untreated, PMW.

CONCLUSIONS

Continuous combined oral HRT with17beta-estradiol plus norethisterone acetate reduces homocysteine levels, mainly after a methionine load. This effect seems to be independent of vitamin status and may have positive implications for the prevention of cardiovascular diseases in PMW.

Specificity and total positive rate of head-up tilt testing potentiated with sublingual nitroglycerin in older patients with unexplained syncope

The aim of this study was to assess the specificity and total positive rate of head-up tilt testing (HUTT) potentiated with sublingual nitroglycerin in detecting the vasovagal origin of unexplained syncope in the elderly, since the diagnostic value of this non-invasive test has not yet been proven in this age group. In a period of 3 years, 128 elderly patients (mean age 71.6+/-5.1 years, 50% males) with syncope of unknown origin, and 101 control subjects matched for age and gender were tilted upright to 60 degrees for 45 minutes. If syncope did not occur, sublingual nitroglycerin (0.4 mg) was administered, and observation was continued for 20 minutes. The positive response was defined as the reproduction of syncope or pre-syncope according to VASIS definition. During the unmedicated phase, syncope occurred in 26 patients (20.3%) and in no members of the control group. After nitroglycerin, 53 patients (41.4%) and 2 control subjects (2%) displayed syncope. The total positive rate of the test was 61.8% with a specificity of 98.0%. In conclusion, HUTT potentiated with sublingual nitroglycerin provides an adequate specificity and total positive rate in old patients with unexplained syncope; therefore it can be proposed as a useful diagnostic tool to detect the vasovagal origin of syncope not only in middle but also in advanced age.

Ursodeoxycholic acid complexation with 2-hydroxypropyl-beta-cyclodextrin increases ursodeoxycholic acid biliary excretion after single oral administration in rats

Complexation of ursodeoxycholic acid (UDCA) with 2-hydroxypropyl-beta-cyclodextrin (HPbetaCD) improves the water solubility and the dissolution rate of UDCA and may therefore increase its bioavailability. We compared the amount and the rate of biliary excretion of UDCA and biliary lipid secretion after a single oral administration of UDCA in 3 different pharmaceutical formulations [UDCA-HPbetaCD ('urso-beta-cyclodextrin'), UDCA suspension and UDCA capsule] at 3 different dosages each, in 11 groups (2 control groups) of bile fistula rats. UDCA excretion increased with an increase in dose, biliary UDCA recovery and peak secretion were significantly higher after administration of UDCA-HPbetaCD than after UDCA in suspension or capsule. This enhancement of biliary excretion may achieve greater UDCA enrichment in the bile acid pool than conventional pharmaceutical UDCA formulations, this giving to UDCA-HPbetaCD a considerable therapeutical potential.

Is body mass index a measure of adiposity in elderly women?

OBJECTIVE

To evaluate the accuracy of body mass index (BMI) as a predictor of body fat in elderly women.

RESEARCH METHODS AND PROCEDURES

A total of 1423 women aged 67 +/- 5 (mean +/- SD, range: 60 to 88) years were consecutively enrolled into the study. Fat mass (FM) was measured using DXA.

RESULTS

BMI explained 72.9% of FM variance (p < 0.0001), with a root mean square error of estimate (RMSE) of 3.5 kg. After standardization of RMSE on the dependent variable as RMSE%, the prediction error equaled 15%. BMI explained 54.8% of FM% variance (p < 0.0001), with an RMSE of 4.1%, corresponding to an RMSE% of 11%.

DISCUSSION

The relatively high RMSE% of the FM and FM%-BMI associations caution against the use of BMI as an adiposity index in individual elderly women. However, an error corresponding to 11% of FM% may be accepted for population studies of body fat in elderly women.

Peroxidation indices and total antioxidant capacity in plasma during hyperhomocysteinemia induced by methionine oral loading

Hyperhomocysteinemia is a risk factor for vascular disease, although its mechanism of action is not fully clear. Different experimental studies have suggested that homocysteine (Hcy) exerts a pro-oxidant effect in the presence of metal ions (Fe and Cu). To test for a similar effect in vivo, we studied plasma markers of lipid and protein oxidation during hyperhomocysteinemia induced by an oral methionine load. Twenty-nine subjects (aged 61 +/- 25 years; 17 women), 25 of whom underwent oral methionine (100 mg/kg) loading, were studied; in every case, we measured total plasma Hcy, malondialdehyde (MDA), conjugated dienes (DIE), and oxidized protein ([PTOX] carbonylic groups) in basal conditions and 4, 6, 8, and 24 hours after methionine loading. Four participants acted as controls. In every case, we also measured total plasma antioxidant capacity (ANTOX) in basal conditions and 8 hours after methionine loading. Eight hours after methionine loading, plasma Hcy increased from 17.6 +/- 11.4 to 54.3 +/- 31.6 nmol/mL, PTOX from 0.33 +/- 0.18 to 0.71 +/- 0.33 nmol/mg protein, DIE from 493 +/- 163 to 590 +/-202 optical density units, and MDA from 1.66 +/- 0.81 to 2.1 +/- 0.93 nmol/mL. There was a significant correlation (Spearman's r) between Hcy and both PTOX (r = .86, P = .01) and MDA (r = .47, P < .05) 8 hours after methionine loading. No significant modifications of the plasma parameters were found during the observation period in controls. ANTOX at 8 hours was significantly (paired ttest) reduced in probands (from 1.74 +/- 0.59 to 1.14 +/- 0.55 mmol/mL, P = .014); no significant difference was observed for plasma ANTOX in controls. Hyperhomocysteinemia due to oral methionine loading induced an increase in plasma oxidation markers. In the absence of hyperhomocysteinemia, no significant modifications were observed. These findings, together with the decrease in ANTOX and the corresponding increase in total plasma Hcy, are consistent with a pro-oxidant effect of acute hyperhomocysteinemia in vivo.

Anthropometry fails in classifying bone mineral status in postmenopausal women

This study tested two hypotheses: (1) that simple anthropometric parameters can be used to identify patients at risk of decreased bone mineral content and (2) that an inverse relationship exists between waist:hip ratio (WHR) and bone mineral density (BMD). Bone mineral content (BMC) and BMD were evaluated by dual-energy X-ray absorptiometry in 1873 free-living women. Of these, 1819 (97%) were post-menopausal. One thousand and thirteen women (54%) had normal BMD, 705 (38%) osteopenia and 155 (8%) osteoporosis. Body weight (Wt), body mass index and arm muscle and fat areas were significantly lower in osteoporotics than osteopenics (p < 0.0001) and in these latter than controls (p < 0.0001). However, values of WHR were similar in all groups (p = ns). Body weight was the anthropometric parameter better correlated with BMC (rho = 0.650, p < 0.0001) and only Wt and age were identified as significant predictors of bone mineral status (normal-BMD/osteopenic/osteoporotic) at polytomous logistic regression (p = 0.0001 for each). However, Wt could not be employed as an indicator of bone mineral status at the individual level because of high variations in BMC for the same level of Wt. Under- (< 5th percentile) and normal-Wt (5th-95th percentile) women had the same frequency of osteopenia (39%) while it was lower in over-Wt (> 95th) women (13%). The frequency of osteoporosis was higher in under- than normal-Wt women (37 vs 7%) and none of the over-Wt women had osteoporosis. This study shows that: (1) simple anthropometric measurements cannot be used to select subjects at risk of decreased BMC and, (2) BMD does not vary with WHR.

N -Acetyl-cysteine reduces homocysteine plasma levels after single intravenous administration by increasing thiols urinary excretion

A decrease of plasma homocysteine (Hcy) may represent a therapeutic promise for reducing the impact of atherosclerosis. N -Acetyl-cysteine (NAC) is a thiol-containing compound interfering with endogenous thiols, cysteine (Cys) and Hcy, by forming with them mixed disulphides with a possibly more efficient renal clearance. The aim of this work was to assess the effect of NAC intravenous infusion on plasma levels of different forms of Hcy and particularly to verify the effect on Hcy renal excretion. We collected basal blood samples at 0.5, 1, 2, 5, 8 and 24 h after the beginning of NAC infusion (50 mg kg(-1)body wt.) and also 24-h urine samples of the day of NAC infusion and of the day before and of the day after the infusion in ten healthy subjects (mean age 73+/-15). Urinary and plasma thiols (Hcy, Cys and NAC) were assayed by HPLC. Both total plasma Hcy (approx. 69%vs basal values) and Cys (approx. 40%vs basal values) fell progressively, reaching a minimum 5 h after infusion start; total free (i.e. not bound to proteins) Hcy (2.2+/-1.8 down from 4.4+/-4.2 nmol ml(-1)) and Cys (70.4+/-39.8 down from 113. 3+/-61.2 nmol ml(-1)) decreased as well. Reduced (thiolic-free form) Hcy and Cys decreased during infusion, though not as pronounced as for the other forms. Percentagewise, out of the total plasma levels, Hcy and Cys total free form and reduced form tended to increase over infusion as well as their difference (i.e. the plasma mixed disulphide moiety), thus supporting the idea that excess NAC displaces thiols from their plasma binding sites forming mixed disulphides. Urinary total Cys and Hcy excretion significantly increased at the end of the day of NAC infusion (tenfold for Cys and fivefold for Hcy) and reduced appreciably on the following day. Also urinary excretion of the free form of Cys and Hcy increased at the end of the day of NAC infusion, although in a lower amount with respect of total amounts, meaning a reduction of percentage Cys and Hcy excreted as the free form; for none of the patients had proteinuria, the 'free' form of urine thiols has to be identified in the 'reduced' form, the difference between the total and free form reflecting the 'mixed disulphide' moiety. NAC intravenous administration induces an efficient and rapid reduction of plasma thiols, particularly of Hcy; our data support the hypothesis that NAC displaces thiols from their binding protein sites and forms, in excess of plasma NAC, mixed disulphides (NAC-Hcy) with an high renal clearance. This effect may represent the start of an alternative approach in the treatment of hyperhomocysteinaemic conditions.

Importance of serum anticholinergic activity in the assessment of elderly patients with delirium

To evaluate the importance of serum anticholinergic activity (SAA) in elderly patients who developed delirium following hospital admission, we performed a cross-sectional study with consecutively referred inpatients in a university geriatric medical ward. Sixty-one patients aged 66 to 95 years (mean age: 79.2+/-11.6; 54% females) were recruited. Delirium was assessed by means of the Confusion Assessment Method, SAA determination, questionnaire for current drug treatment, past medical history and clinical examination, and blood chemistries. Patients were divided into two groups according to the absence (N = 49) or the presence (N = 12) of delirium. Delirious patients showed a significantly higher SAA (23.0 vs 3.9 pmol/mL atropine equivalents, P < .004); they were using antibiotics (P < .05), neuroleptics (P < .002), barbiturates (P < .004), and benzodiazepines (P < .005) more frequently. Subjects with delirium were more likely to have infections and a lower Body Mass Index; they had higher plasma glucose and creatinine. The multivariate analysis identified SAA and use of neuroleptics, and benzodiazepines as the most important features independently associated with delirium. SAA may be a suitable marker for identifying people at risk of developing delirium. Moreover, neuroleptics and benzodiazepines must be carefully used in the elderly because of their relationship with the onset of delirium.

The influence of 2-hydroxypropyl-beta-cyclodextrin on the haemolysis induced by bile acids

Cyclodextrins improve the water-solubility of drugs and can mask their haemolytic effect in parenteral use. Because the mechanism by which bile acids induce haemolysis is poorly understood, it has been investigated in the presence of 2-hydroxypropyl-beta-cyclodextrin (HP-beta-CyD). The haemolytic effect of 1.8 mM solutions of cholic acid, chenodeoxycholic acid (CDCA), deoxycholic acid and ursodeoxycholic acid (UDCA) in isotonic buffer at pH 7.4 was investigated at 37 degrees C in the presence of HP-beta-CyD at concentrations from 0.18 to 32 mM. No haemolytic effect was evident for cholic acid and UDCA. The haemolytic effect of the other bile acids was reduced by addition of HP-beta-CyD and was prevented at a molar ratio of 1:1 owing to complex formation. An HP-beta-CyD:bile acid molar ratio greater than 5:1 had a different effect on the erythrocyte membrane, irrespective of the identity of the bile acid; the effect was in accordance with the complexion affinities. In the absence of HP-beta-CyD, the haemolytic effect of CDCA and deoxycholic acid appeared related to their capacity to form a surface monolayer and to solubilize the components of the erythrocyte membrane. The haemolytic effect observed after complexation of the bile acids appeared to be solely the effect of HP-beta-CyD, which was able to form a reversible inclusion complex with lipophilic components of the erythrocyte membranes at concentrations higher than 12 mM.

Treatment of postprandial hypotension in the elderly

Food intake induces splanchnic vasodilation lasting for at least one hour, which can precipitate in postprandial hypotension, if systolic arterial blood pressure falls by more than 20 mmHg. Postprandial hypotension has a high prevalence in the elderly, above all in subjects receiving hypotensive drugs or in those with disorders of the autonomic nervous system. In our total case series of 567 subjects, the prevalence of postprandial hypotension evaluated by 24-hr blood pressure recording, was 14.5%, increasing to 28% in the oldest group. Since relevant cerebral ischemic symptoms may become manifest, a correct diagnosis of the disorder and both pharmacological and non-pharmacological therapeutical approaches are of great importance for the wellbeing of old patients.

A survey of a centenarian population in Italy, focusing on self-sufficiency and cognition

Eighty-six persons aged 100 years or older (20 males and 66 females) living in urban areas of different Italian regions were examined between 1985 and 1992, aimed at describing the characteristics of centenarians in an entire population. The female/male ratio was 4 to 1, and 69% of the centenarians lived at home. Body mass index was 21.3 in females and 24.5 in males. The subjects typically reported no major diseases, only a few hospital admittances (1.2/lifetime) and a limited use of regular medication (on average: 1.4 drugs). The mothers and fathers of the centenarians lived 76.2 and 74.2 years, respectively. The Activities of Daily Living scale revealed a decrease in instrumental activities, and an adequate self-maintenance in the majority of centenarians; a full score on the Physical Self Maintenance Scale was reached by 10% of the subjects; these scores were not significantly influenced by the isolated sensory deficits but were lower in patients with multiple impairments. The Mini Mental State Examination score was overall 17.7 +/- 8.3 for the group, reaching 24.1 in male and 20.2 in female literate subjects without major hearing or vision defects; these scores varied significantly in relation to sensory deficits and education. In our centenarian population males reached extreme old age less frequently, but with a better quality of life, than females. The good overall performance of the whole population, and especially of the subpopulation without impairments, suggests a selective survival of centenarians, as also demonstrated by the long lifespan of their immediate relatives.

1995 IPA/Bayer Research Awards in Psychogeriatrics. Bihemispheric language disorders in early-stage dementia of the Alzheimer type: evidence from a novel metalinguistic task

Because dementia of the Alzheimer type (DAT) is commonly characterized by bilateral cerebral atrophy, we examined the issue of higher linguistic abilities lateralized to the right cerebral hemisphere (RH) in earlystage DAT. A modified version of an insertion task was administered to 14 patients with probable DAT, 8 right-hemisphere brain-damaged (RHD) patients, 8 left-hemisphere brain-damaged (LHD) patients, and 28 normal elderly (control, CTR) right-handed subjects. The task consisted of presenting the subjects with 53 well-formed sentences; in each a word or syntagm had to be inserted grammatically. Twenty-eight word/syntagm insertions required grammatical role reassignment of a lexical item in the stimulus sentence (shift, sensitive to RHD); 25 insertions implied only semantic reinterpretation of the target sentence (nonshift, sensitive to LHD). The three pathological groups were relatively and similarly impaired on standard aphasia assessment. The performances of the DAT patients, controlled for global cognitive verbal proficiency, verbal cognitive skills, and mood, were found to be significantly worse than the performances of the CTR group on both insertion subtests, whereas there were no significant differences between the DAT and RHD subjects on the shift items or between the DAT and LHD subjects on the nonshift items. Similarly, no differences were noted between the RHD and CTR nonshift scores, or between the LHD and CTR shift scores. On the other hand, the LHD group outscored the RHD group on the shift insertions. A comparison between the two insertion subtests revealed that only the RHD and DAT groups performed significantly worse on the shift than on the nonshift items. Results are consistent with other anecdotally reported RH-specific language-related disorders in early DAT and replicate previous findings of bihemispheric extralinguistic disturbances in these patients.

Influence of a double blind pharmacological trial on two domains of well-being in subjects with age associated memory impairment

This random double-blind trial compares psychological well-being and perceived quality of life in 60 subjects (18 M, 42 F), mean age 61 years, with age-associated memory impairment (AAMI), who were administered a standardised ginseng-containing vitamin complex or placebo for 9 months. We evaluated psychological well-being, in terms of affective status and memory functioning using the Symptom Rating Test [SRT] (depression, anxiety, somatisation, inadequacy) and Randt Memory Test [RMT] (memory index [MI]), respectively, and the quality of life, using the Life Satisfaction in the Elderly Scale [LSES]. At final evaluation, SRT did not differ in the drug and placebo groups, whereas MI and LSES were significantly higher in the drug-treated group. Moreover, the negative correlation between the affective (SRT) and cognitive (MI) component of psychological well-being waned in the drug-treated but not placebo group. In the drug-treated group, a positive correlation emerged between the cognitive index and social contacts, mood and self-concept factors of the LSES. In both groups, the initial negative correlations between quality of life (LSES) and affection (SRT) persisted at the end of the study. Drug-treated AAMI subjects differ from controls in part by improved scores on objective cognitive tests but even more so by modifications of the correlations among indexes of psychological well-being and quality of life.

Improvement of ursodeoxycholic acid bioavailability by 2-hydroxypropyl-beta-cyclodextrin complexation in healthy volunteers

Tablets containing the inclusion complex of ursodeoxycholic acid (UDCA) with 2-hydroxypropyl-beta-cyclodextrin were prepared by direct compression. Plasma concentrations of UDCA were determined in six healthy volunteers after oral administration of tablets containing the inclusion complex or UDCA alone (Ursacol). Following the administration of the complex tablets, the mean area under the plasma concentration curve (AUC) and the maximum UDCA plasma concentration (Cmax) were significantly higher than those obtained after the administration of the commercial ones. Moreover, the time of maximum plasma concentration (tmax) appeared at a shorter time. These results may be explained by the increase of the UDCA dissolution rate via complex formation.

Dietary iron deficiency in the rat. I. Abnormalities in energy metabolism of the hepatic tissue

Severe iron deficiency was induced in rats by rearing nursing dams and their offspring on a diet comprising all the requisite nutrients and trace metals except iron. The iron deficient 5-week-old rats exhibited a severe anemia and a drastic decrease in iron content of the hepatic tissue and of the mitochondrial fraction. Cytochromes c + c1 and b were moderately but significantly reduced. A large increase in liver concentration was observed in iron-deficient animals; whereas there was no modification in total lipid, cholesterol, phospholipid and fatty acid composition of the mitochondrial membrane. Mitochondria from iron-deficient rats presented a partial uncoupling of the oxidative phosphorylation process. This functional derangement was completely reversed by the presence of either bovine serum albumin or L-carnitine plus ATP. This behaviour suggested that endogenous long-chain fatty acids could be primarily involved in the onset of mitochondrial dysfunction. The hepatic energy state of the liver appeared dramatically decreased under the pathological condition of severe iron-deficiency anemia. The possibility of a direct link between the partial loss of coupled functions observed in isolated mitochondria and the heavy energy deficit detected in the liver is discussed.

Validation of the full and short forms of the CAMDEX interview for diagnosing dementia. Cambridge Examination for Mental Disorders of the Elderly

The present study compares the sensitivity and specificity of the short and full forms of the Cambridge Examination for Mental Disorders of the Elderly (CAMDEX) interview in diagnosing dementia. We tested 73 subjects meeting DSM-IIIR criteria for dementia and 61 matched controls. The short version was applied 3 months after the full one to guarantee a relative stability of the tested functions. Referred to an independent clinical rating made at the beginning of the study, the levels of sensitivity and specificity were not significantly different in the two forms and fully comparable with those of the original full English version. Moreover, the scores on analogous sections of the two versions were highly correlated in the demented and control groups. These findings support the hypothesis that the short form of the CAMDEX maintains the psychometric properties of the full one, and consequently can be used in diagnostic routines for a variety of clinical and research purposes.

CDP-choline in the treatment of chronic cerebrovasculopathies

Ninety-two patients affected by chronic cerebrovasculopathy were treated with cytidine diphosphate choline (CDP-choline) 1000 mg/day i.m. or with placebo, in a double-blind study. Two cycles of therapy of 4 weeks each were performed, with an interval of 1 week. There were 46 patients in each group with chronic cerebrovascular diseases, and the two groups were comparable as far as mental deterioration was concerned. The following psychometric tests were administered: Toulouse-Piéron (attention to non-verbal stimuli), Randt Memory test (memory), Sandoz Clinical Assessment of Geriatrics (SCAG, measurement of the behavioral and emotional control). The comparison between the two groups revealed significant improvements in the CDP-choline group compared with the placebo group in some of the attention capabilities (decrease in the number of wrong answers at the Toulouse-Piéron test), of the mnemonic capabilities ('General Information' subtest of Randt Memory test) and behavioral capabilities (SCAG 'affective disturbances' score). No side-effects were detected in the CDP-choline group.