Giorgia Arnone

Plasma homocysteine and inflammation in elderly patients with cardiovascular disease and dementia

Increased levels of plasma total homocysteine (tHcy) may play a role in both cardiovascular diseases (CVD) and old-age dementias via enhancement of vascular inflammation. However, the association between plasma tHcy and serum C-reactive protein (sCRP), taken as a marker of low-grade inflammation, is still uncertain. We investigated this association in normal aging, CVD, and dementia, and examined whether it was modified by the presence of two major comorbid diseases of older age: chronic obstructive pulmonary disease (CPOD) and peptic ulcer (PU). Six hundred-twenty-seven individuals aged > or = 65 yr (74+/-7 yr) were selected for this study: 373 healthy controls; 160 patients with CVD but no evidence of comorbid diseases (CVD+/comorbidity-); 46 patients with CVD and concurrent CPOD and/or PU (CVD+/comorbidity+); and 48 patients with dementia. A positive association between plasma tHcy and serum CRP, independent of several confounders (socio-demographic status, known tHcy and sCRP determinants, inflammation markers, traditional vascular risk factors), was found for CVD+/comorbidity+ (p=0.001; not affected by dementia type) and dementia (p=0.001; not affected by dementia type), but not for CVD+/comorbidity- and controls. The results suggest that the association between plasma tHcy and sCRP is more an aspecific reflection of poor health than a specific correlate of vascular inflammation.

Increased prevalence of coeliac disease in autoimmune thyroiditis is restricted to aged patients.

Patients with autoimmune thyroiditis (AT) have an increased prevalence of coeliac disease (CD), an immune-mediated enteropathy. It is unknown, however, whether prevalence of CD in AT is affected by age. Sera from 514 patients with AT aged <65 yr (46+/-12 yr), 223 patients with AT aged >or=65 yr (71+/-5 yr), 300 controls aged <65 yr (45+/-12 yr), and 300 controls aged >or=65 yr (71+/-6 yr) were tested for IgA anti-tissue transglutaminase (anti-tTG) and antiendomysial antibodies (EmA). If anti-tTG or EmA IgA were positive, jejunal biopsy was performed to confirm CD diagnosis. Prevalence of CD was significantly higher in patients with AT aged >or=65 yr (3.6%, P=0.024) than in patients with AT aged <65 yr (0.6%), controls aged <65 yr and controls aged >or=65 yr (both 0.3%). Prevalence of CD did not significantly differ across patients with AT aged <65 yr, controls aged <65 yr and controls aged >or=65 yr. In conclusion, prevalence of CD is increased in AT but the association is limited to patients aged 65 years or older. Serological screening including anti-tTG-IgA is recommended in these patients.

The Clock-Drawing Test in Elderly Italian Community Dwellers: Associations with Sociodemographic Status and Risk Factors for Vascular Cognitive Impairment

To evaluate whether performance in the clock-drawing test (CDT) is associated with sociodemographic status and risk factors for cognitive impairment, we examined 744 Italian community dwellers aged ≧65 (73 ± 6) years scoring ≧24 on the MMSE. CDT was scored by two different methods, the Sunderland and the Wolf-Klein methods. Sociodemographic, lifestyle, clinical and biochemical variables were also recorded. For both scoring methods, lower CDT scores were associated with age, poor education, increased serum C-reactive protein and history of cancer. Associations of lower CDT scores with increased serum glucose and history of cerebrovascular disease were also found for the method with the highest sensitivity to cognitive impairment. This study shows that in elderly community dwellers, CDT may be not totally free from sociodemographic biases, and that it is associated with risk factors for cognitive impairment and frailty.

Thyroid function tests and early outcomes of acute ischemic stroke in older euthyroid patients

Blood thyroid function tests (TFT) are routinely used to screen for thyroid disorders in several clinical settings. TFT on hospital admission may also be useful prognostic predictors of acute IS: according to recent evidence, poststroke outcome is better in patients with lower thyroid function and worse in those with higher thyroid function. However, previous reports are few and mostly compared patients with thyroid disorders to euthyroid patients. Thyroid disorders are known risk factors for cerebrovascular disease. However, hyperthyroidism is related to cardioembolic IS whereas hypothyroidism is related to atherosclerotic risk factors. Therefore, findings from available studies of TFT might just reflect the worse prognosis of cardioembolic IS compared to other IS subtypes. Another limitation of previous studies is the lack of information for older persons, who represent three quarters of all IS patients. In this paper, we investigated whether serum thyroid stimulating hormone (TSH), free thyroxine (FT4) and free triiodothyronine (FT3) measured on Stroke Unit (SU) admission are associated with early outcomes of acute IS in 775 euthyroid patients aged ≥65 years (mean age 80.1±8.7 years). Two composite outcomes were investigated: poor functional outcome (death during SU stay or disability at SU discharge), and unfavorable discharge setting (death during SU stay, transfer from SU to other acute hospital unit or transfer from SU to long-term care-facilities as opposed to direct discharge home). Analyses were performed using logistic regression models. Curvilinear associations were tested including TFT as polynomial terms. Models were adjusted for demographics, prestroke, and IS-related confounders. We found that lower TSH had a complex curvilinear association with poor functional outcome and that the shape of the associations changed with age. At age 65, the curve was U-shaped: outcome risk decreased with increasing TSH, reached its minimum at TSH near 3.00mUI/L and then started to rise. Between ages 70 and 75, however, the shape of the curve straightened and, starting from age 80 took an inverted U-shape: outcome risk rose with increasing TSH, reached its maximum at TSH values that progressively shifted upward with increasing age (from 1.70mU/L at age 80 to about 2.20mUI/L at age 90), then started to decrease. A linear inverse association was found between FT3 and unfavorable discharge setting. Our study suggests that measurement of TFT on SU admission can provide independent prognostic information for early outcomes of acute IS in older euthyroid patients.

Homocysteinemia and early outcome of acute ischemic stroke in elderly patients.

Plasma total homocysteine (tHcy) is a risk factor for ischemic stroke (IS) but its relationship with IS outcome is uncertain. Moreover, previous studies underrepresented older IS patients, although risk of both hyperhomocysteinemia and IS increases with age. We investigated whether, in elderly patients with acute IS, tHcy measured on admission to the Stroke Unit (SU) is an independent predictor of SU discharge outcomes.

Mortality After Admission to Stroke Unit for Intracerebral Hemorrhage: Effect of Age 80 and Older and Multimorbidity

To the Editor: The incidence of spontaneous intracerebral hemorrhage (ICH) increases exponentially with age, so individuals aged 80 and older are expected to represent a growing proportion of all people admitted to stroke units (SU) for ICH. Age of 80 and older is considered to be a major predictor of ICH mortality independent of characteristics related to ICH severity, but supporting evidence is limited to two small noncontemporary cohort studies and a large contemporary cohort study that did not control for any confounders. Findings from noncontemporary cohorts may not be applicable to individuals with ICH currently benefiting from organized inpatient (SU) care, which has improved ICH survival. Another limitation of these studies is the lack of control for prestroke multimorbidity, which is a known predictor of mortality in stroke. This prospective study investigated whether, in individuals with ICH admitted to a SU, age of 80 and older predicts in-SU mortality independent of multimorbidity. The study included 213 participants aged 80 and older (mean age 84.9 4.0, 57.9% male) and 259 participants younger than 80 (mean age 68.7 9.9, 39.9% male) with spontaneous first-episode ICH consecutively admitted to the SU of the Maggiore Hospital (Bologna, Italy) between October 2007 and December 2013. The Maggiore Hospital ethics committee approved the study. All participants (or their representatives) provided informed consent. Information was collected from medical records. Multimorbidity was defined as a Charlson Comorbidity Index of 2 or greater. Other confounders were sex, hypertension, diabetes mellitus, atrial fibrillation, dementia, prestroke functional impairment (modified Rankin Scale), neurological impairment on admission (National Institutes of Health Stroke Scale), anticoagulation-related etiology, pulse pressure, neuroradiological findings (location and intraventricular extension), and recourse to neurosurgical procedures. The association between aged 80 and older and in-SU mortality was estimated using hazard ratios (HRs) and their 95% confidence intervals (CIs) from Cox proportional hazards regression models adjusted for prestroke and ICH-related confounders. Preliminary analyses showed a significant interaction between age and multimorbidity (P = .04). Based on inspection of survival curves and on previous literature, the interaction was modeled as a time-dependent variable to obtain separate mortality risk estimates for stays or 7 or fewer days and longer than 7 days. Analyses were performed using SPSS version 21 (IBM Corp., Armonk, NY). P < .05 was considered statistically significant. Mortality at 7 days or fewer (69.3% of all deaths) was unrelated to age or multimorbidity (Table 1). By contrast, mortality at longer than 7 days was six times as high for younger than 80 with multimorbidity and aged 80 and older with and without multimorbidity than for younger than 80 without multimorbidity. In individuals with stroke, deaths within the first week are mostly the direct consequence of hemorrhagic injury, whereas deaths in the following weeks are mostly related to medical complications. Therefore, age 80 and older and multimorbidity may fail to affect in-SU mortality during the first week because, at this time, prognosis mainly depends on ICH severity, but after the first week, age 80 and older and multimorbidity may become relevant for managing medical complications. Nevertheless, in the model, the effect of multimorbidity was limited to individuals younger than 80. It may be that, in individuals aged 80 and older, the direct consequences of hemorrhagic injury override those of medical complications for a longer time than in younger individuals. Age-related alterations in cellular architecture and the metabolism of the human brain that may aggravate hematoma expansion and perihematomal edema are consistent with this hypothesis. Moreover, animal models show that brain hemorrhage in older age is associated with excess

Auditory agnosia in a patient with nephrotic syndrome.

A 70-year-old woman with nephrotic syndrome (NS) secondary to membranous glomerulonephritis on immunosuppressive therapy, diabetic nephropathy and hypertension presented with sudden hearing impairment. She had lost the ability to understand speech and transiently expressed some meaningless words. Reading and writing skills were preserved, and she was able to understand written commands. Audiometry revealed mild bilateral sensorineural hearing loss. Brain MRI showed a recent left temporal ischaemic lesion (figure 1; white arrow) and right temporal, left occipital and …