Alberto Cocchi

The effects of cognitive impairment on mortality among hospitalized patients with heart failure

PURPOSE Cognitive impairment is a common, potentially reversible condition among older patients with heart failure. Because cerebral metabolic abnormalities have been associated with reduced survival in younger patients with advanced heart failure, we assessed the effect of cognitive impairment on the survival of older patients with heart failure. METHODS The association between cognitive dysfunction and in-hospital mortality was assessed in 1113 patients (mean [+/- SD] age, 78 +/- 9 years) who had been admitted for heart failure to 81 hospitals throughout Italy. One-year mortality was assessed in 968 patients with heart failure (age, 76 +/- 10 years) participating in the same study. Cognitive impairment was defined as a Hodkinson Abbreviated Mental Test score <7. RESULTS In-hospital death occurred in 65 (18%) of the 357 participants with cognitive impairment and in 26 (3%) of the 756 patients with normal cognition (P <0.0001). Out-of-hospital mortality was 27% (51/191) among patients with cognitive impairment and 15% (115/777) among other participants (P <0.0001). In multivariate Cox regression models, decreasing levels of cognitive functioning were associated with increasing in-hospital mortality; cognitive impairment was associated with an almost fivefold increase in mortality (relative risk = 4.9; 95% confidence interval: 2.9 to 8.3) after adjusting for several potential confounders. CONCLUSION Cognitive impairment is an independent prognostic marker in older patients with heart failure. Assessment of cognitive functioning, even by simple screening tests, should be part of the routine assessment of elderly patients with heart failure.

Association of metabolic syndrome with cognitive function: The role of sex and age

BACKGROUND & AIMS Cognitive impairment is a prevalent condition in older populations, independently associated with disability and mortality. Some studies have suggested a negative correlation between metabolic syndrome (MetS) and cognitive functioning, but results in older subjects are controversial. The aim of this study was to evaluate the association of cognitive performance with MetS in an older unselected population. METHODS We evaluated the association of the Hodkinson Abbreviated Mental Test (AMT) score with MetS, as defined by the National Cholesterol Education Programs ATP-III criteria, in all 353 subjects aged 75+ living in Tuscania (Italy). RESULTS MetS was positively associated with the AMT score in multivariable linear regression analysis, after adjusting (B=0.45, 95% CI=0.04-0.90; p=0.03). When the same regression model was analyzed after stratifying for sex, such an association was significant in women (B=0.76, 95% CI=0.16-1.36; p=0.01), but not in men. Also, when the regression model was analyzed in women, MetS was associated with better cognition (B=1.41, 95% CI=0.51-2.30; p<0.01) among participants aged 80+. CONCLUSIONS MetS is associated with better cognitive performance in community-dwelling elderly; such an association seems to depend upon the oldest female subjects.

Use of calcium antagonists and need for perioperative transfusion in older patients with hip fracture: observational study.

Calcium antagonists inhibit platelet aggregation,1 which may increase the risk of bleeding.2 Whether these drugs increase postsurgical haemorrhage remains controversial,3 but more attention is being given to reducing surgical bleeding because of the risks associated with homologous transfusions.4 We evaluated the haemorrhagic potential of calcium antagonists in hip surgery, which is associated with considerable transfusion requirements. We prospectively evaluated the need for perioperative transfusion in 161 consecutive elderly patients with hip fracture (mean (SE) age 80 (0.5) years; 82% women) who had cemented total hip arthroplasty (85 subjects), hemiarthroplasty (16), or osteosynthesis (60) in 1994-5. One hundred patients had hypertension, 19 diabetes, 47 vascular disease, six liver disease, and 17 peptic disease. Nitrates were taken by 56 patients, angiotensin converting enzyme inhibitors by 44, digitalis by 39, diuretics …

Age-Related Incidence of Reperfusion- and Reoxygenation-induced Ventricular Tachyarrhythmias in the Isolated Rat Heart

Reperfusion- and reoxygenation-induced ventricular tachyarrhythmias were studied on 6-month-old (adult) and 24-month-old (senescent) Langendorff perfused rat hearts. The incidence of arrhythmias was significantly higher in the group of senescent hearts. Furthermore, the reperfusion- and reoxygenation-induced contracture was also more frequent in the group of senescent hearts. The interrelation between contracture and arrhythmias might represent an indirect evidence to suggest that alterations in cell calcium homeostasis have an important role in the origin of both phenomena and, possibly, in their increased incidence in the senescent heart.

Digoxin and cognitive performance in patients with heart failure: a cohort, pharmacoepidemiological survey.

AbstractBackground: Cognitive dysfunction is a prevalent condition among patients with heart failure (HF), and is independently associated with disability and mortality. A large study of patients with atrial fibrillation incidentally demonstrated superior cognitive performance among participants who received digoxin. Interestingly, endogenous cerebral digoxin influences neuronal Na+-dependent transport of calcium and amino acids, as well as the release and reuptake of several neurotransmitters involved in cognitive functioning. Objective: To assess whether treatment with digoxin might improve cognition in patients with HF. Methods: This pharmacoepidemiological cohort study included hospitalized elderly people (age ≥65 years) from the GIFA (Gruppo Italiano di Farmacoepidemiologia nell’Anziano [Italian Group of Pharmacoepidemiology in the Elderly]) study. The GIFA study included 13 598 patients (1590 with a verified diagnosis of HF) without cerebrovascular or Alzheimer’s disease. The main outcome measure was cognitive performance, which was assessed on admission and immediately before discharge using the Hodkinson Abbreviated Mental Test. The diagnosis of HF was verified by the study investigators. Results: Among participants with HF, cognitive performance improved in 25% of 1172 participants who received digoxin compared with 16% of remaining patients (p < 0.0001). Among participants without HF, cognition improved in 23% of 2431 patients receiving digoxin compared with 17% of untreated patients (p < 0.0001). According to logistic regression analysis, the probability (odds ratio) of improving cognitive performance associated with administration of digoxin was 1.69 (95% CI 1.20, 2.38) among patients with HF, and 1.13 (95% CI 0.98, 1.31) among patients without HF, after adjusting for potential confounders. Analysis of the interaction term ‘use of digoxin by diagnosis of HF’ in fully adjusted logistic regression confirmed (p = 0.018) that the association between use of digoxin and improving cognitive performance varied according to diagnosis of HF. Conclusion: Treatment with digoxin might selectively improve cognitive performance among older patients with HF.

Use of calcium antagonists and hemoglobin loss in hospitalized elderly patients: A cohort study

To assess the association between in‐hospital use of calcium antagonists and incident reduction in hemoglobin levels, as well as the impact of individual baseline risk for gastrointestinal bleeding on such an association.

Effects of an Occupational Therapy Program on Functional Outcomes in Older Stroke Patients

Background: During the last decade, occupational therapy has gained increasing importance as component of the rehabilitation programs in disabled patients. Objective: To evaluate the efficacy of occupational therapy programs in patients with a recent stroke. Methods: We selected all patients with a primary diagnosis of ischemic stroke (n = 50) consecutively admitted to the two post-acute Geriatric Rehabilitation Units (CEMI 2 and 3) of the ‘A. Gemelli’ Hospital – Catholic University of Sacred Heart, Rome, Italy. Patients in the unit CEMI 3 (intervention group) received 8 weeks (3 h per day) of a combined rehabilitation program based on occupational therapy and physiotherapy. Patients admitted to the control unit (CEMI 2) received no input from the occupational therapist. Results: Overall, patients had a moderate-to-severe impairment in basic activities of daily living; the mean ADL score was 30.8 (SD ± 7.8) in the intervention group and 30.7 (SD ± 6.1) in the control group (p = 0.9). After 8 weeks of treatment the mean ADL score in the intervention group was 13.2 (SD ± 9.9) compared to 20.3 (SD ± 11.5) in the control group (p = 0.02). Differences between the intervention and control groups were statistically significant for transfers (+2.8 vs. +1.6 points on the ADL scale, p = 0.006), locomotion (+3.4 vs. +1.7 points on the ADL scale, p = 0.01), dressing (+3.0 vs. +1.8 points on the ADL scale, p = 0.01) and self-care (+3.4 vs. +1.8 points on the ADL scale, p = 0.005). Conclusion: Our results show that patients with stroke who received occupational therapy had a greater level of independence in activities of daily living over a period of 8 weeks than patients who did not.

OSTIUM SECUNDUM ATRIAL SEPTAL DEFECT IN THE ELDERLY

Atrial septal defect (ASD) is one of the most common congenital cardiac anomalies in adults. Life expectancy is shortened, and almost 90% of patients die by the age of 60 years. The progression of this congenital disease to congestive heart failure has been related to several factors such as the onset of pulmonary hypertension, arrhythmias, bronchopulmonary infections, or the development of other cardiovascular diseases. We describe three cases of very old patients with significant ASDs and late development of symptoms. Given the higher risks and poorer long‐term results of surgical closure of the defect in advanced age, the indications for such an intervention in elderly patients should be carefully evaluated.

Verapamil disposition and cardiovascular effects in elderly patients after single intravenous and oral doses

SummaryPharmacokinetics and pharmacodynamics of verapamil were studied in 11 elderly subjects (age=79.67±4.74 years) and in 11 middle-aged subjects (age=45±11.37 years) following intravenous (IV), single oral, and long-term oral administration.Plasma verapamil concentrations were determined using high-pressure liquid chromatography (HPLC). Twenty-four hour dynamic Holter electrocardiographic (ECG) recordings were employed to study heart rate (HR) and P-R interval.No difference in plasma half-life, distribution volume, body clearance, and area under the curve (AUC) was observed between the two groups after IV and oral verapamil administration.Blood pressure (BP) and HR were significantly reduced after verapamil IV administration in the elderly group only (p<0.05, p<0.01, respectively). After single and long-term oral administration, variable HR and BP responses were observed in both groups.The P-R prolongation following both IV and single oral doses exhibited a delay with respect to the peak plasma concentration, inducing a definite hysteresis loop. The slope of P-R variations (using a linear pharmacodynamic model) was greater in the elderly both after IV and single oral verapamil administration, but statistical significance was obtained only after the single oral dose (p<0.05). In the elderly group, after long-term oral administration, there was a significant prolongation of the P-R interval (p<0.0001) with respect to the corresponding time point of the 24-hour predrug period. Such variations in pharmacodynamic parameters in the elderly did not, however, cause any clinical problem.In conclusion, verapamil seems to be well tolerated in the elderly as well as in younger patients at similar dosages. However, its use in the elderly requires careful clinical evaluation.

Association of depressive symptoms with bone mineral density in older men: a population-based study

Thirty percent of hip fractures occur in men; nevertheless, the determinants of osteoporosis in men are unclear.