Elisa Zengarini

Underrecognition and Undertreatment of Dementia in Italian Nursing Homes

OBJECTIVE To determine the prevalence of dementia diagnoses and the use of antidementia drugs in a cohort of Italian older nursing home (NH) residents. DESIGN Cross-sectional study. SETTING The NH residents participating in 2 studies: the U.L.I.S.S.E. study and the Umbria Region survey. PARTICIPANTS A total of 2215 nursing home residents. MEASUREMENT Each resident underwent a comprehensive geriatric assessment at baseline by means of the RAI MDS 2.0. Dementia diagnosis was based on ICD-9 codes. RESULTS The prevalence of dementia diagnosis according to ICD-9 codes was 50.7% (n = 1123), whereas 312 subjects had cognitive impairment with a cognitive performance scale score ≥3 without a diagnosis of dementia. Only 56 NH residents were treated (5% of the sample) and the main drugs used were cholinesterase inhibitor, whereas only 1 subject was treated with memantine. Limiting our analysis to patients with mild to moderate Alzheimers disease, who are those reimbursed by the public health care system for receiving antidementia drugs, the percentage rose to 11.3%. CONCLUSION These findings demonstrate a high rate of underdiagnosis and undertreatment of dementia in Italian NH residents. Potential explanations include the lack of systematic assessment of cognitive functions, the limitations to antidementia drug reimbursement, the complexity of the reimbursement procedure itself, and the high prevalence of patients with severe dementia. Older NH residents still lack proper access to state-of-the-art diagnosis and treatment for a devastating condition such as dementia.

The Prevention of Adverse Drug Reactions in Older Subjects

Adverse drug reactions (ADRs) are a public health problem in older subjects, being responsible for a significant morbidity, disability and mortality. Older subjects are more susceptible to develop ADRs mainly due to polypharmacy, multimorbidity and inappropriate prescribing. The prevention of these drug related negative events represents an important aim for physicians treating older patients. Several strategies could potentially be employed, including state of the art education of medical students and physicians concerning principles of geriatric medicine and appropriate prescription in older subjects, reduction of inappropriate drug use by means of computerized decision support systems, pharmacist involvement and comprehensive geriatric assessment, and finally the identification of at risk older patients. However, there is currently a lack of scientific evidence demonstrating that these strategies can achieve a reduction in ADRs and therefore future intervention studies should be performed to evaluate the best intervention to decrease the burden of drug related problems in the older population.

Are ongoing trials on hematologic malignancies still excluding older subjects

Hematologic malignancies are diseases that mainly affect older subjects. Multiple myeloma,[1][1] myelodysplastic syndromes[2][2] and chronic myeloid leukemia[3][3] are common in advanced age. Nevertheless, there is evidence that older patients with hematologic malignancies have often been excluded

Fatigue: Relevance and implications in the aging population

Frailty has been identified as a promising condition for distinguishing different degrees of vulnerability among older persons. Several operational definitions have proposed fatigue as one of the features characterizing the frailty syndrome. However, such a subjective symptom is still not yet sufficiently explored and understood. Fatigue is a common and distressing self-reported symptom perceived by the person while performing usual mental and physical activities, highly prevalent in older people, and strongly associated with negative health-related events. The understanding of fatigue is hampered by several issues, including the difficulty at objectively operationalizing, the controversial estimates of its prevalence, and the complex pathophysiological mechanisms underlying its manifestation. Despite such barriers, the study of fatigue is important and might be encouraged. Fatigue may be the marker of the depletion of the bodys homeostatic reserves to a threshold leading to its psycho-physical functional impairment, mirroring the concept of frailty. Its subjective and symptomatic nature resembles that of other conditions (e.g., pain, depression), which equally affect the individuals quality of life, expose to negative outcomes, and severely burden healthcare expenditures. In the present paper, we present an overview of the current knowledge on fatigue in older persons in order to increase awareness about its clinical and research relevance. Future research on this topic should be encouraged and developed because it could potentially lead to novel interventions against this symptom as well as against frailty and age-related conditions.

Fracture prevention service to bridge the osteoporosis care gap.

Background A care gap exists between the health care needs of older persons with fragility fractures and the therapeutic answers they receive. The Fracture Prevention Service (FPS), a tailored in-hospital model of care, may effectively bridge the osteoporosis care gap for hip-fractured older persons. The purpose of this study was to evaluate the efficacy of the FPS in targeting persons at high risk of future fracture and to improve their adherence to treatment. Methods This was a prospective observational study conducted in a teaching hospital with traumatology and geriatric units, and had a pre-intervention and post-intervention phase. The records of 172 participants were evaluated in the pre-intervention phase, while data from 210 participants were gathered in the post-intervention phase. All participants underwent telephone follow-up at 12 months after hospital discharge. The participants were patients aged ≥65 years admitted to the orthopedic acute ward who underwent surgical repair of a proximal femoral fracture. A multidisciplinary integrated model of care was established. Dedicated pathways were implemented in clinical practice to optimize the identification of high-risk persons, improve their evaluation through bone mineral density testing and blood examinations, and initiate an appropriate treatment for secondary prevention of falls and fragility fractures. Results Compared with the pre-intervention phase, more hip-fractured persons received bone mineral density testing (47.62% versus 14.53%, P<0.0001), specific pharmacological treatments (48.51% versus 17.16%, P<0.0001), and an appointment for evaluation at a fall and fracture clinic (52.48% versus 2.37%, P<0.0001) in the post-intervention phase. Independent of some confounders, implementation of the FPS was positively associated with recommendations for secondary fracture prevention at discharge (P<0.0001) and with 1-year adherence to pharmacological treatment (P<0.0001). Conclusion The FPS is an effective multidisciplinary integrated model of care to optimize identification of older persons at highest risk for fragility fracture, to improve their clinical management, and to increase adherence to prescriptions.

Fatigue as a clinical sign of biological aging: exploratory analyses from the MINDED project.

Fatigue, a common symptom in older persons, is predictive of several major negative conditions, including disability and mortality. It might be of special interest for capturing the progressive decline of physiological reserves, mimicking a clinical manifestation of the “frailty syndrome”. Not surprisingly, fatigue is a defining criterion in several operationalizations of frailty. Frailty has been described as a phase of acceleration in the aging process, a condition of “pathological aging”. The identification of fatigue with a symptom of “biological aging” could thus elevate it to an interesting parameter for the identification of subjects exposed to increased vulnerability to stressors. In the present exploratory analyses, we hypothesized that fatigue could represent a marker of biological aging and be associated with the age-related accumulation of deficits (as proposed by Rockwood et al.). Data are from 45 community-dwelling older adults (aged ≥60 years), recruited as part of the Multidomain Intervention to preveNt Disability in ElDers (MINDED) project. All participants signed an informed consent; the institutional review board of the Centre Hospitalier Universitaire de Toulouse (Toulouse, France) approved the study protocol. Mirroring the “exhaustion” criteria proposed in the “frailty phenotype” by Fried et al., fatigue was defined according to the answers provided by participants to two questions included in the Center for Epidemiological Studies-Depression scale: “How often in the last week have you felt that everything you did was an effort?”, and “How often in the last week have you felt that you could not get going?”. The Frailty Index (FI), an objective tool for measuring the increased vulnerability of the individual to stressors, was developed following a standard procedure. Taking advantage of available data, the index was computed considering a total of 20 healthrelated deficits (i.e. symptoms, diseases, disabilities) not directly related to fatigue. Participants (n = 45) had a mean age of 72.5 years (SD 8.2), and 62.2% were women. The most prevalent diseases were osteoarthritis (46.7%) and hypertension (31.1%). A total of 11 participants (24.4%) reported fatigue. The FI median was 0.15 (interquartile range 0.10–0.25). Participants with fatigue (median 0.20, interquartile range 0.15–0.35) presented significantly higher F.I. compared with those not reporting the symptom (median 0.10, interquartile range 0.09–0.21; Mann–Whitney test P = 0.02). A positive association between fatigue (independent variable) and FI (log-transformed; dependent variable) was confirmed in an ageand sex-adjusted linear regression (β = 0.41, standard error = 0.20; P = 0.05). Our analyses showed that fatigue is significantly associated with the FI. The relationship of fatigue with a marker of age-related accumulation of deficits indicates that fatigue might: (i) represent a clinically relevant marker of aging; and (ii) reflect the underlying vulnerability of the individual’s homeostatic reserves. The present study presented some limitations. Our analyses were carried out in a small sample population, originally recruited for different purposes. The rural origins of the population could affect the external validity of our findings. The cross-sectional design did not allow us to determine any cause–effect relationship between fatigue and frailty. In conclusion, fatigue might play a role in the clinical assessment of older adults. It could suggest a status of pathological aging and, as such, prompt the identification of frailty. Further research is required for developing novel strategies and interventions against age-related and disabling conditions.

The exclusion of older patients from clinical trials regarding heart failure. Causes and consequences

Older subjects are commonly excluded from clinical trials, that are the gold standard to assess the efficacy and safety of new drugs and non pharmacological therapies. The consequence is the lack of evidence about the optimal drug therapy in this population, who makes the highest consumption of drugs, with increased risk of adverse reactions and undertreatment. A clear example is heart failure: data obtained in the context of the European Project PREDICT confirm a widespread exclusion of older individuals from ongoing clinical trials in heart failure, despite the recommendations of regulatory agencies.: Older subjects are commonly excluded from clinical trials, that are the gold standard to assess the efficacy and safety of new drugs and non pharmacological therapies. The consequence is the lack of evidence about the optimal drug therapy in this population, who makes the highest consumption of drugs, with increased risk of adverse reactions and undertreatment. A clear example is heart failure: data obtained in the context of the European Project PREDICT confirm a widespread exclusion of older individuals from ongoing clinical trials in heart failure, despite the recommendations of regulatory agencies.

Clinical Trials on Aging Research

Clinical trials are considered to be one of the best methodologies in health research and they are used primarily to test interventions in medicine. Aging research is no exception for this goal, and clinical trials are used to test different interventions in older adults with a number of variations in this particular research. In addition to drugs, in older adult’s diverse non-pharmacological interventions are experimented for a wide-array of diseases and conditions that are particular for this age group. A careful design and sometimes adaptation of clinical trials methodology are necessary to have accurate results and translate them into actions in everyday clinical care of the older adult. Below, we provide a general and schematic review of the theoretical concept of clinical trials and their variants, followed by examples of interventions and specific outcomes in research on older adults.