Antonio Sgadari

Randomised trial of impact of model of integrated care and case management for older people living in the community

Abstract Objective: To evaluate the impact of a programme of integrated social and medical care among frail elderly people living in the community. Design: Randomised study with 1 year follow up. Setting: Town in northern Italy (Rovereto). Subjects: 200 older people already receiving conventional community care services. Intervention: Random allocation to an intervention group receiving integrated social and medical care and case management or to a control group receiving conventional care. Main outcome measures: Admission to an institution, use and costs of health services, variations in functional status. Results: Survival analysis showed that admission to hospital or nursing home in the intervention group occurred later and was less common than in controls (hazard ratio 0.69; 95% confidence interval 0.53 to 0.91). Health services were used to the same extent, but control subjects received more frequent home visits by general practitioners. In the intervention group the estimated financial savings were in the order of £1125 (

Minimum data set for home care: a valid instrument to assess frail older people living in the community.

1800) per year of follow up. The intervention group had improved physical function (activities of daily living score improved by 5.1% v 13.0% loss in controls; P<0.001). Decline of cognitive status (measured by the short portable mental status questionnaire) was also reduced (3.8% v 9.4%; P<0.05). Conclusion: Integrated social and medical care with case management programmes may provide a cost effective approach to reduce admission to institutions and functional decline in older people living in the community. Key messages Responsibility for management of care of elderly people living in the community is poorly defined Integration of medical and social services together with care management programmes would improve such care in the community In a comparison of this option with a traditional and fragmented model of community care the integrated care approach reduced admission to institutions and functional decline in frail elderly people living in the community and also reduced costs

Is Age an Independent Risk Factor of Adverse Drug Reactions in Hospitalized Medical Patients

Background.Optimal care for frail elderly patients depends on comprehensive assessment. This is especially true in the complex setting of interdisciplinary home care programs. To facilitate comprehensive assessment, as well as to generate a useful, policy-relevant patient database, standardized, multidimensional, and validated instruments are very helpful. Objectives.The aim of the present study was to demonstrate that the Minimum Data Set assessment instrument for Home Care (MDS-HC) can be used to detect functional and cognitive impairment as defined by analogous research instruments. Research Design.This was a cross-sectional correlation study. Subjects.We studied 95 patients admitted to home care services of the Health Care Agency of Bergamo (Italy). Measures.The MDS-HC form was completed for all patients by well-trained nurses, independently of and with nurses blinded to the results from the research rating scales. The Barthel Activities of Daily Living (ADL) Index, the Instrumental Activities of Daily Living of Lawton (IADL), and the Mini Mental State Examination (MMSE) were considered the gold standard. Results.Agreement between the MDS-HC scales and the research rating scales was assessed with Pearson’s correlation coefficient. This coefficient was 0.74 for MDS-ADL versus Barthel Index, 0.81 for MDS-IADL versus Lawton Index, and 0.81 for Cognitive Performance Scale versus MMSE, indicating an excellent agreement. Conclusions.The MDS-HC scales, when performed by trained nurses using recommended protocols, provide a valid measure of function and cognitive status in frail home care patients. These findings point out the overall validity of the functional and clinical data contained in the MDS-HC assessment. Use of the MDS-HC gives the unique opportunity of setting up a database, a prerequisite for all epidemiological evidence-based medicine studies.

Management of heart failure among very old persons living in long-term care: Has the voice of trials spread?☆☆☆★★★

Objective: To study the incidence and the risk factors of adverse drug reactions.

Predictors of mortality in patients with Alzheimer’s disease living in nursing homes

Abstract Background Increasing prevalence, use of health services, and number of deaths have made congestive heart failure (CHF) a new epidemic in the United States. Yet there are no adequate data to guide treatment of the more typical and complex cases of patients who are very old and frail. Methods Using the SAGE database, we studied the cases of 86,094 patients with CHF admitted to any of the 1492 long-term care facilities of 5 states from 1992 through 1996. We described their clinical and functional characteristics and their pharmacologic treatment to verify agreement with widely approved guidelines. We evaluated age- and sex-related differences, and we determined predictors of receiving an angiotensin-converting enzyme (ACE) inhibitor by developing a multiple logistic regression model. Results The mean age of the population was 84.9 ± 8 years. Eighty percent of the patients 85 years of age or older were women. More than two thirds of patients underwent frequent hospitalizations related to CHF in the year preceding admission to a long-term care facility. Coronary heart disease and hypertension were the most common causes. Half of the patients received digoxin and 45% a diuretic, regardless of background cardiovascular comorbidities. Only 25% of patients had a prescription for ACE inhibitors. The presence of cardiovascular comorbidity, already being a recipient of a large number of medications, a previous hospitalization for CHF, and admission to the facility in recent years were associated with an increased likelihood of receiving an ACE inhibitor. The presence of severe physical limitation was inversely related to use of ACE inhibitors, as were a series of organizational factors related to the facilities. Conclusions Patients in long-term care who have CHF little resemble to those enrolled in randomized trials. This circumstance may explain, at least in part, the divergence from pharmacologic management consensus guidelines. Yet the prescription of ACE inhibitors varies significantly across facilities and depends on organizational characteristics. (Am Heart J 2000;139:85-93.)

Enalapril prevents cardiac fibrosis and arrhythmias in hypertensive rats

OBJECTIVES To identify factors associated with mortality in patients with Alzheimer’s disease, and to evaluate whether these factors vary according to severity of cognitive impairment. METHODS Data were from the SAGE database which includes information on all residents admitted between 1992 and 1995 to all Medicare/ Medicaid certified nursing homes of five US states. We conducted a longitudinal follow up study (median 23 months) on 9264 patients aged 65 years and above with a diagnosis of Alzheimer’s disease. Patient data including demographic characteristics, dementia severity, comorbidity, and other clinical and treatment variables were collected with the Minimum Data Set. Information on death was derived through linkage to Medicare files. Baseline characteristics were used to predict survival in univariate and multivariate Cox proportional hazard models. RESULTS Overall mortality rate was 50%, with a first year rate of 25.7%. Increased age (risk ratio (RR) 1.83; 95% confidence interval (95% CI) 1.65–2.03, for patients 85+ years), male sex (RR 1.81; 95% CI 1.70–1.94), limitation in physical function (RR 1.45; 95% CI 1.27–1.66), a condition of malnutrition (RR 1.31; 95%CI 1.23–1.39), the presence of pressure ulcers (RR 1.24; 95% CI 1.13–1.36), a diagnosis of diabetes mellitus (RR 1.32; 95% CI 1.21–1.43), and of cardiovascular diseases (RR 1.22; 95% CI 1.14–1.30) were independent predictors of death, regardless of the severity of baseline dementia. Sensory problems (hearing and vision) and urinary incontinence were associated with increased mortality only among patients with less severe dementia. The presence of disruptive behaviour, aphasia, and a diagnosis of Parkinson’s disease were not related to survival. African-Americans and other minority groups were less likely to die relative to white people. CONCLUSIONS Age, sex, functional limitation, and malnutrition seem to be the strongest predictors of death for patients with Alzheimer’s disease in nursing homes. Altogether, severity of dementia has no influence on survival, yet the predictive role of certain variables depends on the degree of impairment. Minority groups have a reduced risk of death relative to white people.

Gender differences in the relation between comorbidity and mortality of patients with Alzheimer’s disease

To evaluate the effects of hypertension on cardiac hypertrophy, on myocardial structure, and on ventricular arrhythmias, 27 3-month-old spontaneously hypertensive rats were treated with enalapril (10 ing/kg) daily for 11 months and compared with 26 untreated control rats. Systolic arterial pressure was significantly decreased in treated rats, and at the end of the experiment, it was 199±3 mm Hg (treated) versus 237±3 mm Hg (controls) (p<0.001). At this time, spontaneous arrhythmias and induced arrhythmias either by programmed electrical stimulation (train of stimuli +1 or 2 extrastimuli) or by trains of eight stimuli at decreasing coupling intervals were observed in isolated heart preparations. Comparing enalapril-treated and control rats, spontaneous arrhythmias (9 of 27 versus 20 of 26, respectively, p<0.01), programmed stimulation-induced arrhythmias (3 of 26 versus 12 of 23, respectively; p<0.01), and trains of stimuli-induced arrhythmias (4 of 26 versus 14 of 19, respectively, p< 0.001) were less frequent in the enalapril group. Left ventricular weight was decreased in treated rats by 18% (p<0.001). Enalapril administration diminished the fraction of myocardium occupied by foci of replacement fibrosis normally occurring in control rats by 59% (/?< 0.001). Finally, a significant correlation was found between left ventricular weight, the extent of myocardial fibrosis, and the occurrence of ventricular fibrillation. It was concluded that chronic treatment with enalapril, which resulted in attenuation of systemic arterial pressure by limiting cardiac hypertrophy and myocardial fibrosis, decreases the propensity of the heart of hypertensive rats to arrhythmogenesis.

Gender differences in predictors of mortality in nursing home residents with AD

Objective: To investigate whether differences in the number and type of comorbid conditions may help explain the gender gap in mortality among patients with AD. Background: The prevalence and incidence of AD are higher among women, who also have more severe cognitive impairment and accelerated decline. However, men have an exceedingly higher mortality. Methods: The authors conducted a retrospective cohort study on 5,831 men and 17,918 women with a diagnosis of AD. Data were from the Systematic Assessment of Geriatric drug use via Epidemiology (SAGE) database, which includes information on residents of 1,492 nursing homes in five US states (1992–1995). Men and women were compared with respect to demographic characteristics, dementia severity, psychiatric and behavioral symptoms, indicators of physical disability, and general health status. Also compared were age- and race-adjusted prevalence of all comorbid conditions at each level of cognitive impairment. In survival analyses, the risk of death and of hospitalization were determined by gender and level of cognitive impairment. Finally, gender-related differences in the intensity of pharmacologic treatment were examined. Results: Women were older than men (83 ± 7 versus 81 ± 7 years) and were more likely to exhibit severe cognitive deterioration (27% versus 19% among men). Overall, there were no significant gender-related differences on several measures of physical disability (activities of daily living performance, gait and history of falls, incontinence, pressure sores), but significantly more women were underweight (45% versus 37% among men). However, the age- and race-adjusted 1-year mortality rate was 17% for women and 31% for men. The mortality rate of women at the highest degree of dementia severity was lower than the rate for men with minimal cognitive impairment. At any level of cognitive impairment, the prevalence of arrhythmia, chronic obstructive pulmonary disease, PD, and cancer was higher among men. Women were also less likely to be hospitalized, and they received fewer medications for each given disease. Conclusions: The survival advantage of women with AD relative to men may occur as a result of fewer comorbid clinical conditions associated with the diagnosis of dementia.

The impact of legislation on psychotropic drug use in nursing homes: a cross-national perspective.

Objective: To evaluate whether the excess mortality in men with AD can be explained by a gender difference in the predictors of mortality. Methods: The authors studied 2,838 men and 6,385 women over 65 years of age with AD admitted, between 1992 and 1995, to 1 of nearly 1,500 nursing homes in five U.S. states (Kansas, Maine, Mississippi, New York, and South Dakota). Resident level data including sociodemographic characteristics, dementia severity, measures of physical disability, comorbidity, and other clinical variables were collected with the Minimum Data Set. Information on death was derived through linkage to Medicare enrollment files; the median follow-up was 23 months. Baseline characteristics were used to predict age at time of death in Cox proportional hazard models. Results: Men with AD had an increased risk of mortality relative to women, adjusted for differences in the distribution of age and race. The most important predictors of death in men were those related to the disease itself. These were the severity of dementia and the occurrence of episodes of delirium. Instead, death among women was associated with measures of disability, namely, impairment in performing the activities of daily living, presence of pressure sores, malnutrition, and comorbidity. Conclusion: These data suggest that the underlying mechanisms for AD may be different in men and women. Future studies of survival and progression of AD need to examine men and women separately.

Oxidative imbalance and cathepsin D changes as peripheral blood biomarkers of Alzheimer disease: A pilot study

OBJECTIVES: To quantify the impact of legislation on nursing home residents, psychotropic drug use, and the occurrence of falls in the US compared with five countries with no such regulation.