Bernardo Salani

Does the Clock Drawing Test Predict Cognitive Decline in Older Persons Independent of the Mini-Mental State Examination?

OBJECTIVE: To evaluate the value of the Clock Drawing Test (CDT) in predicting cognitive deterioration over a 4‐year period, independent of baseline cognitive status evaluated by the Mini‐Mental State Examination (MMSE).

Functional Recovery of Elderly Patients Hospitalized in Geriatric and General Medicine Units. The PROgetto DImissioni in GEriatria Study

OBJECTIVES: To investigate the characteristics of patients who regain function during hospitalization and the differences in terms of functional outcomes between patients admitted to geriatric and general medicine units.

Transdermal Buprenorphine for the Treatment of Chronic Noncancer Pain in the Oldest Old

CONTEXT Chronic pain increases with age, and in the elderly, comorbidities and polypharmacotherapy make the choice of treatment for pharmacological pain control a complex matter. OBJECTIVES We conducted a multicenter, prospective, observational study to evaluate the efficacy and safety of the buprenorphine transdermal delivery system (TDS) in elderly patients with chronic noncancer pain. The aim was to assess the cognitive and behavioral status of patients during treatment. METHODS The study included 93 patients (69 women and 24 men); the mean age was 79.7 years, and in most cases, the pain was due to osteoarthritis. Almost three-quarters (74.2%) of the patients had suffered pain for more than 12 months. The treatment was buprenorphine TDS, starting from a dose of 17.5 μg/h. Outcomes were assessed using the Mini-Mental State Examination (MMSE), the 17-item Hamilton Depression scale (HAM-D 17), the Neuropsychiatric Inventory, the Barthel Index, the Short-Form Health Survey (SF-12), a verbal numeric rating scale, and the Cumulative Illness Rating Scale (CIRS). RESULTS Buprenorphine treatment was associated with a decrease in pain severity without negative effects on the central nervous system. On the HAM-D scale, there were reductions in both the psychological and somatic scores. On the MMSE, values at the beginning and end of the study were comparable. Evaluation by SF-12 showed improvements in physical and mental status. CIRS values at baseline and at the end of the study were superimposable, indirectly confirming the tolerability and safety profile of the drug. CONCLUSION Our experience confirms the analgesic activity and safety of buprenorphine TDS in the elderly. There was an improvement in mood and a partial resumption of activities, with no influence on cognitive and behavioral ability.

Age-related hemodynamic effects of intravenous nitroglycerin for acute myocardial infarction and left ventricular failure

Acute hemodynamic effects of intravenous nitroglycerin (NTG) were assessed in 24 patients with acute myocardial infarction and left ventricular failure, and results were compared between 2 groups of different age (group A--65 years or less, n = 12; group B--75 years or more, n = 12). Overall, hemodynamic effects of NTG consisted of an increase in stroke volume index and left ventricular stroke work index (+21 and +23%), coupled with a 16% reduction in systemic vascular resistance, and of a marked decrease in right atrial and pulmonary artery (PA) pressures. The hemodynamic end-point (5 to 10% reduction in mean systemic arterial pressure) used for NTG titration was achieved with a significantly lower dose in group B, in which a greater percent reduction in mean PA and mean PA wedge pressures was also observed. However, because effects of NTG on systemic vascular resistance were similar in groups A and B, it was concluded that the vasodilating action of NTG is maintained in advanced age, as opposed to what has been demonstrated for beta-adrenergic agents.

Acute functional decline before hospitalization in older patients.

Acute diseases and related hospitalization are crucial events in the disabling process of elderly individuals. Most of the functional decline occurs in the few days before hospitalization, as a result of acute diseases in vulnerable patients. The aim of the present study was to identify determinants of prehospital components of functional decline.

Age-related changes in the pharmacodynamics of intravenous glyceryl trinitrate

Comparable hemodynamic effects were obtained administering a much lower intravenous dose of glyceryl trinitrate (GTN) in elderly than in younger patients. The pharmacodynamics and kinetics of GTN were thus assessed in 2 groups of patients with acute my-ocardial infarction (group A: ≤ 65 years, 6 patients; group B: ≥ 75 years, 6 patients). The arterial and venous dose-concentration relationship and the associated hemodynamic changes at end-point (EP: 10% reduction in mean systemic arterial pressure) were similar in the 2 groups. However, in older subjects EP was reached at a lower GTN infusion rate (0.11 ± 0.04 vs 0.33 ± 0.11 μg·kg−1·min−1, mean ± S.D.; p < 0.001), and with lower arterial and venous drug concentrations (arterial [GTN]: 1.2 ± 0.1 vs 4.6 ± 1.2 ng·ml−1; p < 0.01; venous [GTN]: 0.09 ± 0.05 vs 0.35 ± 0.15 ng·ml−1; p < 0.05), whereas overall GTN kinetics appeared to be substantially independent of age. Thus, the enhanced efficacy of GTN in advanced age seems to stem mainly from pharmacodynamic changes, which may be the consequence of dampened baroreceptor reflexes, as suggested by a lower heart rate increase per unitary fall in systolic arterial pressure observed in group B (0.12 ± 0.07 vs 0.41 ± 0.29 b·min−1·mmHg−1; p < 0.05). (Aging 2: 59–64, 1990)

Improved Exercise Tolerance by IV Fructose-l,6-Diphosphate in Chronic, Stable Angina Pectoris

The effect of IV fructose‐1,6‐diphosphate (FDP) on transient, reproducible myocardial ischemia was evaluated in ten patients, aged 50 to 66 years, with chronic, stable exertional angina. FDP or placebo (glucose) were administered between basal and posttreatment ergometric stress testing; an identical procedure was repeated in each patient with the second treatment on the following day according to a single‐blind, cross‐over design. FDP improved exercise tolerance and total work capacity, significantly delaying the onset of ST‐segment depression and angina. Nevertheless, the critical level of the rate × pressure (R × P) product, causing appearance of myocardial ischemia, was not remarkably changed. However, the R × P product at same workload was significantly lower after FDP. These results suggest that improved exercise tolerance might have resulted from peripheral (increased oxygen delivery to skeletal muscle) rather than from central (cardiac) effects of FDP.

The Severity of Acute Illness and Functional Trajectories in Hospitalized Older Medical Patients

Background: Acute diseases and hospitalization are associated with functional deterioration in older persons. Although most of the functional decline occurs before hospitalization in response to the acute diseases, the role played by comorbidity in the functional trajectories around hospitalization is unclear. Methods: Observational prospective study of 696 elderly individuals hospitalized in two Italian general medicine wards. Functional status of the elderly patients at 2 weeks before hospitalization (baseline), at hospital admission, and at discharge was measured by the Barthel Index. Comorbidity was measured at admission by the Geriatric Index of Comorbidity (GIC), a tool mostly based on illness severity. The association of GIC with changes in functional status before hospitalization (between baseline and admission), during hospitalization (between admission and discharge), and in the overall period between baseline and discharge was assessed by logistic regression analyses. Hospitalization-associated disability (HAD) was defined as a functional decline between baseline and discharge. Results: Illness severity (GIC 3–4 vs 1–2: odds ratio [OR] 2.2, 95% CI [confidence interval] 1.5–3.3, p < .0001) and older age significantly predicted prehospital functional decline (between baseline and admission). Illness severity (OR 1.9, 95% CI 1.2–3, p = .004) and older age were also predictive of HAD, even after adjustment for each coded primary discharge diagnosis. After adjustment for the occurrence of prehospital functional decline, however, illness severity and older age were not predictive of HAD anymore. Conclusions: The severity of illnesses was strongly associated with adverse functional outcomes around hospitalization, but frailty, intended as functional vulnerability to the acute disease before hospitalization, was a stronger predictor of HAD than illness severity and age.

Case Report: Mental Confusion, Diplopia, and Inability to Stand in an 82‐Year‐Old‐Man

To the Editor: We have read with interest the article by Keller et al. on the prevention of weight loss in demented patients living in special care units (SCUs). Results show that body weight can be maintained in demented patients living in SCUs, where malnutrition is a frequent condition. We would like to contribute to the discussion with our own data, obtained from a prospective observational study of demented patients living in two SCUs. We determined the prevalence of malnutrition through biochemical and anthropometric data, evaluating nutritional changes with 6 and 18 months of follow-up after a nutritional intervention program. Study was performed on 40 elderly residents in SCUs (part of the Alzheimer Care Plan of Regione Lombardia, Italy); 31 were affected by Alzheimer’s disease (AD), four had vascular dementia (VD), four had mixed AD-VD, and one had Lewy Body disease. Patients were mainly female (72%), with severe cognitive impairment (mean Mini-Mental State Examination score standard deviation55.1 5.9), moderate to severe behavioral disturbances (neuropsychiatric inventory535.7 15.3), and functional impairment (Barthel Index, activities of daily living5 45.9 22.3); they were affected by multiple comorbid diseases (number of diseases54.9 2.9, burden of disease57.4 2.9) and experienced clinical adverse events the year before the study (number of infections52.3 1.6). A low number of neuroleptic drugs and antidepressants was prescribed (0.5 0.5 and 0.7 0.5, respectively), with behavioral interventions preferred over pharmacological treatment of behavioral and psychological symptoms of dementia. Nutritional status was analyzed using anthropometric (weight, body mass index) and biochemical (albumin, transferrin (total iron body capacity (TIBC)), cholesterol, and hemoglobin serum levels) indexes. An albumin level of 3.5 g/dL was used as the cutoff for malnutrition, as previously done in another study. To understand the characteristics of feeding difficulties, the Eating Behavioral Scale was introduced (range 0–18). This scale includes variables potentially influencing feeding, such as the ability to begin the meal and keep attention on food, the use of a knife, and the ability to chew and swallow without difficulty. Higher scores indicate greater levels of independence. Dental status, feeding time, and percentage of food eaten were also assessed for each patient (visual staff evaluation). At the beginning of the study, 19 of 40 patients (47.5%) were judged to be malnourished. Those patients underwent a nutritional program that consisted of modifications of diet composition and quality and consistency of food based on a patient’s preferences or ability to chew, swallowing difficulties, and dental status (soft diets). Time spent by nurses for feeding was increased, as was help feeding, ranging from stimulation to supervision to assisted feeding. Environmental modifications were performed to find the most comfortable place for each patient. Finally, nutritional supplements were prescribed for patients whose daily caloric intake was low (hypercaloric and hyperproteic diets). Nutritional oral supplement prescription was reviewed monthly. Nutritional parameters were assessed at 6 and 18 months of follow-up. After a 6-month intervention trial, the number of malnourished patients fell to 10 (25%). Baseline malnourished patients had a statistically significant improvement of albumin levels and a trend, still not significant, toward improvement of other nutritional parameters: cholesterol, TIBC, and hemoglobin (Table 1). Weight and body mass index did not show significant changes. At 18 months of follow-up, data confirmed the previous evaluation by showing a substantial stability in albumin levels. Similar results were obtained for TIBC and cholesterol, whereas body weight did not change significantly (Table 1). Survival rates at 18 months of follow-up were not different from those reported in the study by Keller et al.

Disability and Quality of Life in Old Age

In the past century life expectancy in Europe has increased by more than 20 years. Mortality rates in the elderly have sharply decreased. The oldest-old segment of the population, those age 85 years and older, is currently growing faster than any other age group. Older persons are likely to suffer from one or more diseases or disabilities (Hermanova, 1989; Hermanova et al.,1992). In spite of this, little information is presently available on the dynamic development of chronic diseases, and on their effect on the quality of life in old age.