Giorgetta Cappa

Low folate levels in the cognitive decline of elderly patients and the efficacy of folate as a treatment for improving memory deficits

The relevance of low folate levels as determinants of cognitive deficits and the usefulness of folate supplementation in the treatment of cognitive deficits was reviewed from the literature. Over 40 papers and book chapters published in English, French, German, Italian and Spanish were examined. This represents those papers published in the international literature in the last 10 years which were identified by various key words including folate, cognition and aging (or ageing). Among these papers, only 13 articles specifically addressed issues relevant to the criteria adopted for this review. The remaining papers were principally concerned with depression and or with other pathologies of the aged associated with folate deficiency. Although the specific role of low folate levels in the physiopathology of dementia is still under debate, a growing consensus is emerging in the literature where low folate as well as cobalamin levels in aged patients with cognitive deficits are being considered as a sign of functional problems in the absorption and utilization of vitamins, and not merely as a sign of bad eating habits. In studies where folate compounds were evaluated for treatment effects, the results of a majority of investigations indicated that folate treatment was effective in lessening cognitive deficits. Treatment efficacy, however, has not yet been sufficiently demonstrated by these results because there were no controlled studies and the methodology was heterogeneous for the evaluation of cognitive characteristics. An ad hoc double-blind, controlled versus placebo pilot study was undertaken to evaluate the efficacy of folic acid in 30 aged patients with abnormal cognitive decline and folate level below 3 ng/ml to better understand the value of this type of intervention. Our results from this preliminary study demonstrated that patients treated with folic acid for 60 days showed a significant improvement on both memory and attention efficiency when compared with a placebo group. The intensity of memory improvement was positively correlated with initial severity of folate deficiency. On the contrary, the severity of initial cognitive decline was unrelated to the degree of folate deficiency.

Risk of cognitive decline in older patients after carotid endarterectomy: an observational study.

OBJECTIVES: To determine whether patients undergoing carotid endarterectomy (CE) for symptomatic left internal carotid artery (LICA) stenosis have greater risk of cognitive decline than patients with asymptomatic LICA disease or right internal carotid artery (RICA) disease.

Malnutrition in an elderly demented population living at home

Malnutrition is a frequent complication for elderly demented patients even if they live at their own home with the assistance of a caregiver. The present study evaluates nutritional characteristics of a population of 130 non-institutionalized demented patients. The results show that the mini nutritional assessment (MNA) total score is inversely related with the neuro-psychiatric inventory (NPI) score and that the level of cognitive impairment is related with the nutritional status: patients with mild cognitive impairment (MCI) showed a mean MNA score higher than patients affected by Alzheimers disease (AD) or vascular dementia (VaD). Moreover, patients depressed, with hallucinations or with behavioral disturbs are more exposed to underfeeding than only cognitively impaired subjects. In conclusion, an appropriated evaluation of nutritional status could prevent and treat nutrition-related problems even in the elderly demented patients living at home.

Length of Stay in the Emergency Department and Occurrence of Delirium in Older Medical Patients

To determine whether emergency department (ED) length of stay before ward admission is associated with incident delirium in older adults.

Pro-Inflammatory Cytokine Genes Influence the Clinical Features of Frontotemporal Lobar Degeneration

Background/Aims: Recent studies suggested a role for pro-inflammatory mediators in frontotemporal lobar degeneration (FTLD). The objective of this study was to evaluate the association of functionally active polymorphisms in pro-inflammatory cytokine genes with the occurrence and the clinical features of the disease. Methods: Using a case-control study, we compared allelic and genotypic frequencies of several polymorphisms in the interleukin (IL)-1α, interleukin (IL)-1β, interleukin (IL)-6 and tumor necrosis factor (TNF)-α genes between 110 FTLD patients and 119 healthy controls. Results: No significant association between the examined polymorphisms and the disease was found. However, in comparison with remaining genotypes, patients carrying the T/T genotype of the IL-1β gene showed a significantly lower age at onset of the disease. In addition, scores of the Frontal Assessment Battery were significantly modified by the IL-6 –174G>C polymorphism. Conclusion: Our findings support a role for pro-inflammatory cytokine genes in the pathogenesis of frontotemporal lobar degeneration.

COSTS OF THE IN-HOME PATIENTS AFFECTED BY DEMENTIA

In 2000, Alzheimers disease (AD) and other dementias were the third most expensive health conditions in the USA and in 2005 their annual costs amounted to more than

Stress in professional care-givers working with patients with dementia: a hypothesis-generating study

148 billion. An observational, non-randomized study aimed to evaluate direct costs of demented patients in their homes. Two hundred thirty-six informal caregivers have been enrolled. A financial support, represented by a disability living allowance (15.3%) or attendance allowance (3.4%), was presented in just 19.7% of the cases. Patients receiving assistance from an employed carer were 39% with a mean cost of 800 Euro/month. Receiving assistance from an employed carer is not correlated with cognitive and functional impairment, with the age of the caregiver and with the duration of the disease (t=1.03; t=-0.86; t=1.41; t=-0.16, respectively). The informal caregivers declared that they thoughts about the possibility of institutionalize the patient were 20.9%. The present study underlines the discrepancy between subjects having assistance from an employed caregiver and subjects receiving financial supports. It often happens that patients not reaching the minimum requisites for social assistant or financial support, need at least a supervision.

Prevalence, predictors and clinical impact of potentially inappropriate prescriptions in hospital-discharged older patients: A prospective study: PIP outcomes

Background and aims: Caregiving can be extremely stressful, especially when patients’ ability to communicate is impaired. While the stress undergone by relatives assisting their loved ones has been widely investigated, fewer data can be found about the stress in healthcare professionals. The aim of this study is to evaluate whether a specific training course could be related to a reduction in the levels of stress of professional care-givers working with patients suffering from dementia. Methods: Work-related levels of stress of study participants were evaluated with the Staff Stress Measure Dementia Care Scale, at baseline and four months after completion of an eight-month training course. Results: We found no significant correlation between care-givers’ age, gender, marital status, years of employment or perceived economic status, and their stress levels at baseline. Patients’ characteristics were not related with care-givers’ stress at baseline. The mean level of stress was significantly reduced (34.64±4.15 vs 26.64±3.82, p<0.001) between baseline and the study endpoint. Conclusions: Increased knowledge of management of patients affected by dementia could help professional care-givers to reduce their work-related stress. Our results add to the evidence of the benefit of personnel support in reducing levels of stress at work.

Nonlinear analysis of electroencephalogram in frontotemporal lobar degeneration.

Potentially inappropriate prescriptions (PIP) have been highly reported in older patients, but few studies have investigated their association with adverse clinical outcomes. The present study aimed to evaluate the prevalence and predictors of PIP in hospital‐discharged older adults, and to explore the association of PIP with death and rehospitalization.

Nutritional patterns in elderly patients with dementia of Alzheimer type

Frontotemporal lobar degeneration (FTLD) is a form of dementia characterized by a profound alteration in personality and social behavior and is associated with atrophy in the frontal and temporal brain regions. Despite recent advances, diagnosis of FTLD remains challenging. In the last decade, different studies have combined EEG analysis with mathematical models and theories that consider EEG signals as the result of nonlinear chaotic activity. The aim of the present study was to determine whether new nonlinear dynamic analysis can provide useful information on brain activity in FTLD patients. 19-lead EEG was recorded in patients with clinical diagnosis of FTLD and in healthy controls under two different conditions: closed eyes and open eyes. A nonlinear measure of complexity, correlation dimension (D2), was calculated. Our results show an increase in D2 in healthy individuals when the eyes are open, in keeping with an increase in information processing. Conversely, in FTLD patients, no increase in D2 occurred in the open eyes condition, and D2 was significantly lower than that observed in controls. Our results suggest that the dynamic processes underlying the EEG are less chaotic and complex in FTLD patients compared with normal individuals, thus providing important information on both brain functioning and possible clinical diagnostic applications.