Carla Scarafiotti

Substitutive “Hospital at Home” Versus Inpatient Care for Elderly Patients with Exacerbations of Chronic Obstructive Pulmonary Disease: A Prospective Randomized, Controlled Trial

OBJECTIVES: To evaluate hospital readmission rates and mortality at 6‐month follow‐up in selected elderly patients with acute exacerbation of chronic obstructive pulmonary disease (COPD).

Hospital at Home for Elderly Patients With Acute Decompensation of Chronic Heart Failure A Prospective Randomized Controlled Trial

BACKGROUND Although the hospital is the standard venue for short-term medical care, it may be hazardous for older persons. This study was performed to evaluate the feasibility and effectiveness of a physician-led hospital-at-home service for selected elderly patients with acute decompensation of chronic heart failure (CHF). METHODS Prospective, single-blind, randomized controlled trial with 6-month follow-up for patients 75 years or older admitted to the hospital from April 1, 2004, through April 31, 2005, for acute decompensation of CHF. Patients were randomly assigned to the general medical ward (n = 53) or to the Geriatric Home Hospitalization Service (GHHS; n = 48). The GHHS provides diagnostic and therapeutic treatments by hospital health care professionals in the home of the patient. RESULTS Patient mortality at 6 months was 15% in the total sample, without significant differences between the 2 settings of care. The number of subsequent hospital admissions was not statistically different in the 2 groups, but the mean (SD) time to first additional admission was longer for the GHHS patients (84.3 [22.2] days vs 69.8 [36.2] days, P = .02). Only the GHHS patients experienced improvements in depression, nutritional status, and quality-of-life scores. CONCLUSIONS Substitutive hospital-at-home care is a viable alternative to traditional hospital inpatient care for elderly patients with acutely decompensated CHF. This type of care demonstrated clinical feasibility and efficacy in comparison with its alternative. Trial Registration clinicaltrials.gov Identifier: NCT00623571.

Health and functional status in elderly patients living in nursing homes

Socio-economic background, functional status, multiple pathology and medical conditions requiring care have been evaluated in 506 elderly subjects living in nursing homes in Turin (Italy). In the sample 78.8% are women, mean age 84.2 years, only 21.2% are men, mean age 76.3 years. Particularly in the oldest age classes women are more represented than men. Most subjects (94.3%) require help in at least one Activity of Daily Living (ADL). Part of the sample (21.2%) comes from home, 13.2% from acute wards, 9.1% from long term care wards, 6.3% from mental hospitals, 26.3% from residential homes. Education level is rather low. Before retirement, many men were workmen (38.3%), while many women were housewives (46.6%). Multiple pathology is very common: 23.7% of patients suffer from 4 pathologies, more than 5 diseases are present in 18.8%, while only 4.7% of subjects have less than two pathologies. Half of the sample (52.6%) is affected by dementia, 37.6% by cardiovascular diseases, 29.1% by chronic obstructive lung disease and 25.5% by stroke. Bone fractures are present in 22.1% of the subjects. Severe impairments in strength and/or motility in at least two limbs affect 43.7% of patients, double incontinence 49.2%, severe disturbances in speech and communication 35.4%. The prevalence of care needs is higher in women compared with men. More females than males need aid in walking, help in eating, diapers, pressure sores prevention and bedposts.

Symptoms as predictors of functioning in the community-dwelling elderly

This survey was carried out to explore the relationship between symptoms and functional status in the elderly living at home. The setting is an urban area of Turin (Northern Italy). A cross-sectional screening for 20 symptoms was completed in 747 subjects, aged 75 and older. Dependence in basic Activities of Daily Living (ADL) and in Instrumental Activities of Daily Living (IADL), Short Portable Mental Status Questionnaire and Cumulative Illness Rating Scale were also ascertained. A discriminant analysis was performed to determine the potential value of symptoms in predicting functional impairment. The mean number of symptoms was 6.0 per subject (+/-S.D. 3.3) and dependence in ADLs was 8.2%. Amongst a 20-symptom list, six symptoms (fatigue, memory loss, indigestion, nutrition, hearing and speaking problems), either alone or in association, showed sufficient discriminatory power to identify dependence in ADLs (sensitivity=72%), mental impairment (72%), psychological distress (80%), but not dependence in IADLs (48%). Symptoms are common in the free-living elders, but their functional status is good. A short (6 items) formal screening for symptoms may be a simple way to predict functioning and to rapidly manage problems.

Evaluation of cognitive and behavioral status of institutionalized elderly. Follow-up two and seven years

Summary The evolution of cognitive and behavioral disturbances over time in institutionalized elderly has not yet been widely studied. Our research was performed on a sample of 318 subjects admitted to a nursing home in Torino, Italy. Among them, anamnestic and clinical data identified 142 demented patients. In the baseline assessment Mini Mental State Examination (MMSE) and Crichton Geriatric Evaluation Rating Scale were included. After two years, 148 subjects including 50 patients who had been diagnosed as demented, could be retested with the same tools. Basal MMSE values were low for the demented subgroup (10.7 ± 5.6 points) but also for the subjects classified as non demented (21.8 ± 6.1 points). This finding can be explained by the advanced age of the sample (mean 80.2 ±9.2 years), the low education level (mean 5.97 ± 2.7 years) and socio-economic status and by the concomitance of multiple illnesses leading non-demented patients to seek institutional care. MMSE scores after two years showed a slight, significant improvement in the 98 non-demented patients, while a significant decline in cognitive performance was seen in the demented group. Behavioral problems at start were much more pronounced in the demented subgroup (Crichton mean score 28.4 ± 8.0 vs. 20.5 ± 5.7) but they remained relatively stable, while in the non-demented subgroup a mild impairment was seen over the two-year observation period. Seven years after admission, 39 surviving patients, including 13 elderly who had been diagnosed as demented, were re-evaluated with MMSE and Crichton. Both scores were found to worsen in the whole sample regardless of the diagnosis on admission. Functional and mental decline was slight in the first two years of observation and much more pronounced in the following five years.

Carotid plaques, aging, and risk factors for atherosclerosis

The prevalence of extracranial carotid artery atherosclerosis and its relations to principal cardiovascular risk factors at different ages was evaluated in a sample of general population. High resolution B-mode ultrasonography was used to investigate the carotid district in 457 subjects (231 males and 226 females, mean age 55.4+18.7 years, range 18-97 years) of the metropolitan area. The ultrasonographic findings were then related to primary risk factors. Carotid plaques were found in 178 subjects (38.5%). Prevalence of atherosclerosis, number of plaques and percentage of stenosis have been observed to increase with age. The main cardiovascular risk factors resulted significantly associated with carotid atherosclerosis in the total series and, more strongly, in subjects under 65 years. In the group aged 65 years and over, most of these associations were no longer found. In the multiple logistic regression model, analysis of subjects under 65 years showed positive and independent associations between carotid atherosclerosis and age (p<0.0001), cigarette smoking (p< 0.001), number of cigarettes smoked each day (p<0.01), and a negative association with HDL/total cholesterol ratio (p<0.001). The analysis of subjects aged 65 years or more showed positive independent associations only with age (p<0.001) and male gender (p<0.01). In conclusion, there is a high prevalence of asymptomatic carotid atherosclerosis in the general population, particularly in advanced age. In the elderly the association between risk factors and carotid atherosclerosis has not yet been found.

Hemorheolocical and photoplethysmographical modifications with aging

The association of hemorheological patterns with the common risk factors for atherosclerosis is widely known. There are only few data about hemorheological modifications with aging. The objective of our study was to evaluate the relationships of blood and plasma viscosity, the whole blood and red cell filterability, and the amplitude of photoplethysmographical wave to aging and to some risk factors for atherosclerosis. The study involved 278 healthy women, mean age 55.3 +/- 11.9 (SD) years. Blood viscosity was positively correlated to body mass index (BMI), total cholesterol/HDL ratio, triglyceridemia, glycemia and hematocrit. Plasma viscosity was positively correlated to age, systolic blood pressure, glycemia, and fibrinogen contents. Whole blood filterability was negatively correlated to diastolic blood pressure, triglyceridemia, glycemia, hematocrit, and fibrinogen contents. Red cell filterability was negatively correlated to age, hematocrit, and fibrinogen. The amplitude of photoplethysmographical wave is inversely correlated to age and systolic blood pressure. Our findings show an increase of plasma viscosity, a decrease of red cell filterability and of the amplitude of photoplethysmographical wave with advancing age. These modifications may contribute to the microcirculatory troubles often evident in aging individuals.