Manuela Antocicco

Recommendations to Prescribe in Complex Older Adults: Results of the CRIteria to Assess Appropriate Medication Use Among Elderly Complex Patients (CRIME) Project

The occurrence of several geriatric conditions may influence the efficacy and limit the use of drugs prescribed to treat chronic conditions. Functional and cognitive impairment, geriatric syndromes (i.e. falls or malnutrition) and limited life expectancy are common features of old age, which may limit the efficacy of pharmacological treatments and question the appropriateness of treatment. However, the assessment of these geriatric conditions is rarely incorporated into clinical trials and treatment guidelines. The CRIME (CRIteria to assess appropriate Medication use among Elderly complex patients) project is aimed at producing recommendations to guide pharmacologic prescription in older complex patients with a limited life expectancy, functional and cognitive impairment, and geriatric syndromes, and providing physicians with a tool to improve the quality of prescribing, independent of setting and nationality. To achieve these aims, we performed the following: (i) Existing disease-specific guidelines on pharmacological prescription for the treatment of diabetes, hypertension, congestive heart failure, atrial fibrillation and coronary heart disease were reviewed to assess whether they include specific indications for complex patients; (ii) a literature search was performed to identify relevant articles assessing the pharmacological treatment of complex patients; (iii) A total of 19 new recommendations were developed based on the results of the literature search and expert consensus. In conclusion, the new recommendations evaluate the appropriateness of pharmacological prescription in older complex patients, translating the recommendations of clinical guidelines to patients with a limited life expectancy, functional and cognitive impairment, and geriatric syndromes. These recommendations cannot represent substitutes for careful clinical consideration and deliberation by physicians; the recommendations are not meant to replace existing clinical guidelines, but they may be used to help physicians in the prescribing process.

Association of pain with behavioral and psychiatric symptoms among nursing home residents with cognitive impairment: Results from the SHELTER study

Summary Evidence from a large sample of frail elderly people in nursing homes reveals an association between pain and behavioral and psychiatric symptoms. Abstract The etiology of behavioral and psychiatric symptoms is generally considered to be multifactorial, and these symptoms often indicate a need for care or assistance, which may include the presence of uncontrolled pain. The aim of this cross‐sectional study was to assess the association of pain with behavioral and psychiatric symptoms in a population of nursing home (NH) residents with cognitive impairment in Europe. Data are from the SHELTER project, which contains information on NH residents in 8 countries. Pain was defined as any type of physical pain or discomfort in any part of the body in the 3 days before the assessment. The mean age of 2822 cognitively impaired residents entering the study was 84.1 (standard deviation 9.1) years, and 2110 (74.8%) were women. Of the total sample, 538 residents (19.1%) presented with pain. After adjusting for potential confounders, pain was significantly and positively associated with socially inappropriate behavior (odds ratio [OR] 1.37; 95% confidence interval [CI] 1.04–1.80), resistance to care (OR 1.41; 95% CI 1.08–1.83), abnormal thought process (OR 1.48; 95% CI 1.16–1.90), and delusions (OR 1.48; 95% CI 1.07–2.03). A borderline inverse association was observed with wandering (OR 0.74; 95% CI 0.55–1.00). In conclusion, this cross‐sectional study provides evidence from a large sample of frail elderly showing an association between pain and behavioral and psychiatric symptoms. Treatment models that put together assessment and treatment of pain and evaluate their effect on behavioral and psychiatric symptoms are needed.

Mini Mental State Examination over time in chronic hemodialysis patients

OBJECTIVE Cognitive impairment is relatively common in end-stage renal disease patients on chronic hemodialysis, but the course of cognitive function deterioration in hemodialysis patients is essentially unknown. The present study aimed to evaluate if changes in Mini Mental State Examination (MMSE) over time in hemodialysis (HDP) and elderly (EP) patients differ significantly and determine the variables associated with such possible changes. METHODS In 80 HDP and 160 EP, the MMSE was assessed at baseline and after 1 year. Patients were stratified at baseline and at 1 year into three groups according to the MMSE: normal cognitive function >23; mild-moderate cognitive dysfunction: 18-23; severe cognitive dysfunction: <18. Univariate and multivariate analyses were performed to determine the variables associated with MMSE change over time RESULTS One-year median reduction of MMSE was greater in HDP (from 24 to 21) than in EP (from 26 to 25) (P<.0001). A higher percentage of HDP than EP switched from normal to mild-moderate or severe MMSE group (P<.0001). At baseline, MMSE was negatively correlated with hypertension (P=.013), angina (P=.007) and Beck Depression Inventory (P=.041) and positively correlated with education (P=.017) and male gender (P=.015). No factors were found to be significantly associated with change of MMSE between baseline and month 12 in HDP. CONCLUSION One-year MMSE reduction was greater in HDP that in EP. No factors were associated with MMSE reduction in HDP. However, it remains likely that cardiovascular comorbidities and low haemoglobin levels are related to such decline.

Shorter Telomeres in Peripheral Blood Mononuclear Cells from Older Persons with Sarcopenia: Results from an Exploratory Study

Background: Telomere shortening in peripheral blood mononuclear cells (PBMCs) has been associated with biological age and several chronic degenerative diseases. However, the relationship between telomere length and sarcopenia, a hallmark of the aging process, is unknown. The aim of the present study was therefore to determine whether PBMC telomeres obtained from sarcopenic older persons were shorter relative to non-sarcopenic peers. We further explored if PBMC telomere length was associated with frailty, a major clinical correlate of sarcopenia. Methods: Analyses were conducted in 142 persons aged ≥65 years referred to a geriatric outpatient clinic (University Hospital). The presence of sarcopenia was established according to the European Working Group on Sarcopenia in Older People criteria, with bioelectrical impedance analysis used for muscle mass estimation. The frailty status was determined by both the Fried’s criteria (physical frailty, PF) and a modified Rockwood’s frailty index (FI). Telomere length was measured in PBMCs by quantitative real-time polymerase chain reaction according to the telomere/single-copy gene ratio (T/S) method. Results: Among 142 outpatients (mean age 75.0 ± 6.5 years, 59.2% women), sarcopenia was diagnosed in 23 individuals (19.3%). The PF phenotype was detected in 74 participants (52.1%). The average FI score was 0.46 ± 0.17. PBMC telomeres were shorter in sarcopenic subjects (T/S = 0.21; 95% CI: 0.18–0.24) relative to non-sarcopenic individuals (T/S = 0.26; 95% CI: 0.24–0.28; p = 0.01), independent of age, gender, smoking habit, or comorbidity. No significant associations were determined between telomere length and either PF or the FI. Conclusion: PBMC telomere length, expressed as T/S values, is shorter in older outpatients with sarcopenia. The cross-sectional assessment of PBMC telomere length is not sufficient at capturing the complex, multidimensional syndrome of frailty.

Pattern of medication use among older inpatients in seven hospitals in Italy: results from the CRiteria to assess Appropriate Medication use among Elderly complex patients (CRIME) project.

BACKGROUND Prescribing pharmacological treatment for hospitalized older patients represents a challenge for physicians. In particular, hospitalized older adults present with acute and chronic diseases, which may require multiple treatments and increase their susceptibility to adverse drug reactions. Patterns of drugs use have rarely been investigated in these patients. OBJECTIVE To describe patterns of drugs use among hospitalized older adults participating in the CRiteria to assess Appropriate Medication use among Elderly complex patients (CRIME) project. METHODS We performed a cross-sectional multicentre study based on data from the CRIME project, a study performed in geriatric and internal medicine acute care wards of 7 Italian hospitals. The only two exclusion criteria were: age < 65 years old and unwillingness to participate in the study. Participants were assessed at hospital admission and followed until discharge. RESULTS Mean (Standard Deviation) age of 1123 participants was 81.5 (7.4) years, with 629 (56%) being women and 572 participants (51%) were admitted from Emergency Room. Mean length of stay was 11.2 (6.7) days. Mean number of drugs used greatly varied before (6.2, SD 3.2), during (10.6, SD 5.6) and after (7.1, SD 3.1) hospitalization. No difference in the number of drugs used during hospital stay was observed across age groups. During hospital stay, drugs for acid related disorders (77.9%) and antithrombotic agents (76.8%) were the most commonly used drugs, followed by drugs acting on the renin-angiotensin system (58.0%) and diuretics (57.1%). Very common was the use of psycholeptics (34.3%) and psychoanaleptics (22.4%). CONCLUSION Use of multiple drug treatments is common in hospitalized older adults and hospitalization is associated with a substantial increment in the number of drugs used, with no differences across age groups.

Symptoms of depression and anxiety over time in chronic hemodialysis patients

BACKGROUND Little is known about the course of the symptoms of depression/anxiety and the factors predictive of such courses in hemodialysis (HD) patients. This study aimed at evaluating the possible changes of Beck Depression Inventory (BDI) and Hamilton Anxiety Rating Scale (HARS) over time, and factors associated with such changes in HD patients. METHODS We screened 110 patients for study participation. Of these, 30 were excluded because of dialytic vintage <6 months, alcohol/substance abuse, inability to answer to the questionnaires, diagnosis of psychotic or neurological disorders or recent stressful life events. Eighty patients were included in the study and BDI, HARS, Charlson Comorbidity Index, SF-36 Vitality Subscale, Mini-Mental State Examination (MMSE), routine laboratory parameters, C-reactive protein (CRP) and interleukin-6 were measured at baseline. The 18-month course of BDI and HARS was measured in patients with baseline BDI ≤14. RESULTS At baseline, 42 patients had BDI >14 and 38 patients ≤14. In patients with BDI ≤14, the BDI decreased/remained stable in 19 and increased in 19. Patients with increased BDI had lower baseline MMSE (22.6 ± 2.6 vs. 25.9 ± 2.7, p=0.004) and higher baseline serum CRP (6.07 ± 4.2 vs. 1.64 ± 1.59, p=0.003). At multivariate analysis the relationship between BDI changes and MMSE and serum CRP was statistically significant. In 25 patients, the HARS decreased/remained stable, while in 13 it increased. Characteristics of the 2 groups of patients did not differ significantly. CONCLUSIONS In a meaningful proportion of HD patients, symptoms of depression worsen over time, and CRP and MMSE are independent predictors of such change.

Fatigue Is Associated with Increased Risk of Mortality in Patients on Chronic Hemodialysis

Background: Little is known about the correlation between fatigue and survival in patients on chronic hemodialysis and whether fatigue is an independent predictor of outcome above and beyond the effects of depression. The aim of the present study was to determine if fatigue is a predictor of mortality in patients on chronic hemodialysis (CHP) and if this occurs independently of the symptoms of depression. Methods: CHP referring to the Hemodialysis Service of the Università Cattolica of Rome, Italy between November 2007 and January 2015 were studied. Demographic, clinical, and laboratory data were recorded for each patient at the moment of the inclusion in the study. Fatigue levels were assessed in patients using the Vitality Scale of SF-36 (SF-36 VS), functional ability by the activities of daily living (ADL) and instrumental activities of daily living (IADL), depressive symptoms through the Geriatric Depression Scale (GDS), cognitive function using the Mini Mental State Examination (MMSE), and comorbidity through the Charlson Comorbidity Index (CCI). Patients were grouped into four groups (quartiles): Quartile 1 (Q1), >65; Q2, ≥50 to <65; Q3, ≥35 to <50; Q4, <35. Results: We studied 126 patients: 11 were transplanted and 53 died. Patients who later died were older and had a worse cognitive performance, higher CCI and GDS scores, lower ADL, IADL and SF-36 VS scores, lower serum creatinine and albumin levels. Kaplan-Meier survival was significantly lower in Q4 than in Q1 (p = 0.0001). According to Cox regression analysis, higher fatigue (Q4) was associated with a higher risk of mortality (HR, 95% CI: 5.29, 2.2-12.73). Conclusion: Fatigue is associated with an increased risk of mortality in CHP, with the relationship independent of symptoms of depression. Fatigue should be assessed routinely and may be a potential target of interventions that aim to reduce mortality in CHP.

Characteristics of Adults with Down Syndrome: prevalence of age-related conditions

Introduction: In the last decades, life expectancy of persons with Down syndrome (DS) has dramatically increased and it is estimated that they will be living as long as the general population within a generation. Despite being included among the progeroid syndromes, because of the presence of features typically observed in older adults, DS is still regarded as a disease of pediatric interest. Because limited knowledge is available on the clinical characteristics of adults with DS, this study aimed to assess clinical and non-clinical features of this population and to describe similarities to the geriatric population. Methods: In this study, we described 60 adults with DS evaluated at the Day Hospital of the Geriatric Department of the Policlinico A. Gemelli, Università Cattolica del Sacro Cuore in Rome. Individuals were assessed through a standardized protocol. Results: The mean age of study participants was 38 years (range, 18–58 years) and 42 (70.0%) were women. Geriatric conditions were highly prevalent: severe cognitive impairment was diagnosed in 39 (65.0%) participants, behavioral symptoms were present in 25 (41.7%), and functional impairment in 23 (38.3%). Six (10.0%) participants lived in institutions and 11 (18.3%) were diagnosed as obese. The mean number of drugs used was 2.4; use of psychotropic drugs was highly prevalent. The most common chronic diseases were thyroid problems (44, 73.3%), followed by mood disorders (19, 31.7%), osteoporosis (18, 30.0%), and cardiac problems (10, 16.7%). Geriatric conditions and chronic diseases were more prevalent among participants aged ≥40 years. Conclusion: Several similarities between older adults and adults with DS were observed. Comorbidities, geriatric conditions, cognitive and functional deficits, and social problems are highly prevalent in both populations, contributing to the high complexity of these patients’ assessment and treatment.

Necrotizing pneumonia and sepsis due to Clostridium perfringens: a case report

Clostridia are uncommon causes of pleuropulmonary infection. Clostridial species infecting the pleuropulmonary structures characteristically cause a necrotizing pneumonia with involvement of the pleura. Most cases have iatrogenic causes usually due to invasive procedures into the pleural cavity, such as thoracentesis or thoracotomy, or penetrating chest injuries. Rarely clostridia pleuropulmonary infections are not related to these factors. The clinical course of pleuropulmonary clostridial infections can be very variable, but they may be rapid and fatal. We report a rare case of necrotizing pneumonia and sepsis due to Clostridium perfringens not related to iatrogenic causes or injuries in an 82 years old woman.

Qualities of fatigue in patients on chronic hemodialysis

We aimed to assess the relationship among fatigue qualities (FQ) and the association of FQ with various characteristics of chronic hemodialysis (HD) patients. In 68 HD patients, we assessed the Charlson Comorbidity Index (CCI), the Geriatric Depression Scale score (GDS), the Mini Mental Status Examination (MMSE), and measured the laboratory parameters. In addition, patients answered to six questions about FQ (Tiredness: Do you feel tired much of the time? Emotional: Do you feel that life is empty? Cognitive: Do you have trouble concentrating? Sleepiness: Have you had difficulty sleeping in the past month? Weakness: Have you had muscle weakness in the past month? Lack of energy: Do you feel full of energy?). At least one FQ was reported by 62 patients. Muscle weakness (61.7%) was the most frequent and cognitive fatigue (22%) the least. Physical FQ were all more common than the mental ones. Correlation between the two mental FQ (emotional and cognitive) was 0.381 (p = 0.002). Six patients reported none of the FQ, 20 one FQ, 13 two FQ, and 29 three or more FQ. CCI and GDS were associated with all FQ and MMSE with all FQ but sleepiness. Patients reporting ≥3 FQ were older, had more comorbidities, more symptoms of depression, and a lower MMSE score. At multivariate linear regression analysis, the GDS was the only significant predictor of the number of FQ. HD patients report a variety of qualities of fatigue and the number of FQ is independently associated with symptoms of depression.