Marianna Noale

Self-rated health among older adults: a cross-national comparison

Self-rated health (SRH) may have different implications in various social and cultural settings. However, few studies are available concerning SRH among older persons across countries. The aim of this study was to analyse whether there are cross-national differences in the association between status characteristics, several diseases common among older persons, activities of daily living (ADL), and SRH. The study base was the Comparison of Longitudinal European Studies on Aging (CLESA), which includes data from six population-based studies on aging conducted in Finland, Israel, Italy, The Netherlands, Spain and Sweden. The study population comprised 5,629 persons, with participants from all countries except Italy. Logistic regression analyses were used to assess the relationship between status characteristics, health conditions, ADL and SRH. To examine whether the association among status characteristics, health conditions, ADL and outcome differed across the CLESA countries, interaction terms defined as “variable*country” were considered separately for each variable. Regression analyses revealed that sex, education, lifetime occupation, heart disease and respiratory disease were differently distributed across countries. Among homogeneous factors, marital status (OR=1.21), hypertension (OR=1.41), stroke (OR=1.67), diabetes (OR=2.15), cancer (OR=1.47), musculoskeletal diseases (OR=2.44), and ADL (OR=2.72) turned out to be significantly associated with fair or poor SRH. The results indicate that there are differences in self-ratings of health across countries. These differences cannot be explained entirely by status characteristics, self-reported diseases or functional ability. However, an important finding was that in all countries most of the indicators of medical and functional health were homogeneously associated with SRH.

Dementia and Disability: Impact on Mortality

Dementia is known to be associated with excess mortality. Physical disability, as a marker of dementia severity, is often considered the last step on the way from disease to death. The objective of this study was to investigate the direct effect of dementia on mortality in a population-based study, carried out in Italy, with a sample of 5,632 individuals aged 65–84 years. At 4-year follow-up, 998 participants had died. The independent predictors of death were: age (75–84 years; HR 2.63, CI = 2.11–3.27), male sex (HR 1.45, CI = 1.22–1.74), coronary heart disease (HR 1.61, CI = 1.34–1.94), moderate and severe instrumental activities of daily living disability (HR 1.98, CI = 1.30–3.03 and HR 3.26, CI = 2.09–5.09, respectively), diabetes in subjects with a survival time greater than 23 months (HR 0.68, CI = 0.43–1.08) and dementia (HR 2.07, CI = 1.62–2.66). These data provide evidence that dementia per se, independently from physical disability, is a strong predictor of death in the elderly.

Metabolic syndrome and all-cause and cardiovascular mortality in an Italian elderly population: the Progetto Veneto Anziani (Pro.V.A.) Study.

OBJECTIVE—The purpose of this study was to explore the association of metabolic syndrome and each of its components with all-cause and cardiovascular mortality in a general Italian elderly population. RESEARCH DESIGN AND METHODS—Metabolic syndrome, diagnosed by National Cholesterol Education Program Adult Treatment Panel III criteria, all-cause mortality, and cardiovascular mortality, was evaluated in 2,910 subjects aged ≥65 years of the Progetto Veneto Anziani (Pro.V.A.) Study during a mean follow-up time of 4.4 years. RESULTS—After multivariable adjustment, metabolic syndrome was associated with increased all-cause mortality in all subjects (hazard ratio 1.41 [95% CI 1.16–1.72], P = 0.001), among men (1.42 [1.06–1.89], P = 0.017), and among women (1.47 [1.13–1.91], P = 0.004). High glucose in all subjects (1.27 [1.02–1.59], P = 0.037) and in women (1.61 [1.16–2.24], P = 0.005) and low HDL cholesterol in women (1.48 [1.08–2.02], P = 0.014) were predictors of all-cause mortality, even independently of the interactions of different metabolic syndrome components. After multivariable adjustment, metabolic syndrome was also associated with increased cardiovascular mortality in all subjects (1.60 [1.17–2.19], P = 0.003), among men (1.66 [1.00–2.76], P = 0.051), and among women (1.60 [1.06–2.33], P = 0.025). High glucose (2.17 [1.28–3.68], P = 0.004) and low HDL cholesterol (1.78 [1.07–2.95], P = 0.026) among women predicted higher cardiovascular mortality. CONCLUSIONS—In this general Italian elderly population, among metabolic syndrome components, all-cause mortality is better predicted by high glucose in all subjects and in women and by low HDL cholesterol in women, whereas cardiovascular mortality is better predicted by high glucose and low HDL cholesterol in women.

Vitamin K, vertebral fractures, vascular calcifications, and mortality: VItamin K Italian (VIKI) dialysis study.

Vitamin K (vitamin K1 or phylloquinone and vitamin K2, a series of menaquinones [MKs]) is involved in the production of bone and matrix amino acid γ‐carboxy‐glutamic acid (Gla) proteins, regulating bone and vascular calcification. Low vitamin K concentrations are associated with increased risks of fractures and vascular calcification, and frequent complications in hemodialysis patients. We carried out an observational study to establish the prevalence of vitamin K deficiency and to assess the relationship between vitamin K status, vertebral fractures, vascular calcification, and survival in 387 patients on hemodialysis for ≥1 year. We determined plasma levels of vitamin K compound, bone‐Gla‐protein, matrix‐Gla‐protein, and routine biochemistry. Vertebral fractures (reduction in vertebral body height by ≥20%) and aortic and iliac calcifications were also investigated in a spine (D5–L4) radiograph. Three‐year patient survival was analyzed. Important proportions of patients had deficiency of MK7 (35.4%), vitamin K1 (23.5%), and MK4 (14.5%). A total of 55.3% of patients had vertebral fractures, 80.6% had abdominal aorta calcification, and 56.1% had iliac calcification. Vitamin K1 deficiency was the strongest predictor of vertebral fractures (odds ratio [OR], 2.94; 95% confidence interval [CI], 1.38–6.26). MK4 deficiency was a predictor of aortic calcification (OR, 2.82; 95% CI, 1.14–7.01), whereas MK5 deficiency actually protected against it (OR, 0.38; 95% CI, 0.15–0.95). MK7 deficiency was a predictor of iliac calcification (OR, 1.64; 95% CI, 1.03–2.60). The presence of vertebral fractures was also a predictor of vascular calcifications (OR, 1.76; 95% CI, 1.00–3.08). Increased alkaline phosphatase and C reactive protein (CRP), age, and cerebrovascular events were predictors of mortality. Our study suggests that the vitamin K system may be important for preserving bone mass and avoiding vascular calcification in hemodialysis patients, pointing out a possible role of vitamin K in bone and vascular health. Based on our results, we suggest that the general population should also be studied for vitamin K deficiency as a possible cause of both vertebral fractures and vascular calcification.

Predictors of mortality: an international comparison of socio-demographic and health characteristics from six longitudinal studies on aging: the CLESA project

PURPOSE Multiple factors contribute to mortality in the elderly, but the extent to which traditional factors contribute independently to mortality in different countries is not known. Our objective is to determine the differential impact of socio-demographic variables, selected diseases, health habits and disability on all-cause mortality, among older people living in five European countries and Israel. METHODS From six longitudinal studies on aging (TamELSA-Tampere (Finland), CALAS-Israel, ILSA-Italy, LASA-Netherlands, AL-Leganés (Spain), SATSA-Sweden), a harmonized common database was created in the context of the CLESA Project (Cross-national determinants of quality of life and health services for the elderly). A common five-year follow-up was used. RESULTS The highest mortality rate was found in Tampere among females (98.7%) and in Israel among males (108.3%), whereas the lowest was observed in Leganés for males (72.3%) and in The Netherlands for females (44.6%). In multivariate models, some predictors were homogeneously, significantly distributed across the six countries, including older age (HR = 1.57) and male sex (HR = 1.60) among the socio-demographic variables; smoking status (HR = 1.15) and alcohol consumption (HR = 0.81) among the health habits variables; presence of heart disease (HR = 1.34), diabetes (HR = 1.46), cancer (HR = 1.93), respiratory disease (HR = 1.19), and disability (HR = 2.92) among the health status variables. Marital status, education, and drug use did not have homogeneous effects in the six countries. DISCUSSION This large international study shows that multiple factors contribute to increased risk of all cause mortality among older people and that most risk factors are similar across countries. Disability, age greater than 80 years, cancer and male sex were identified as the strongest common risk factors of mortality.

Cross-national determinants of quality of life from six longitudinal studies on aging: The CLESA Project

Background and aims: The Comparison of Longitudinal European Studies on Aging (CLESA) Project, here presented for the first time, is a collaborative study involving five European and one Israeli longitudinal study on aging. The aim of this paper is to describe the methodology developed for the harmonization of data and the creation of a Common Data Base (CDB), and to investigate the distribution of some selected common variables among the six countries. The design of each study is briefly introduced and the methodology leading to the harmonization of the common variables is described. Methods: The study base includes data from five European countries (Finland, Italy, the Netherlands, Spain, Sweden) and Israel, for older people aged 65–89 living both in the community and in institutions (total, 11557 subjects). For two age classes (65–74 and 75–84), the prevalence ratios or the mean values of the following selected variables are provided: a) sociodemographic variables; b) health habits; c) health status; d) physical functioning; e) social networks and support; and f) health and social services utilization. Results: Statistically significant differences were found between most of the investigated characteristics across the CLESA countries, with very few exceptions. While some of the differences found may be due to cultural variations, others require further investigation and should be encompassed in the main framework of the Project, which is to identify predictors of hospitalization, mortality, institutionalization and functional decline. Conclusions: A common data base is available for the study of the aging process in five European and one Israeli population. These data provide a unique opportunity to identify common risk factors for mortality and functional decline and increase our understanding of country-specific exposures and vulnerability.

Predicting mortality in older patients. The VELCA Study

Background and aims: Mortality at older age, during and after hospitalization, can be determined by several factors, beyond the direct cause for hospital admission, which are not yet fully understood. The aim of this study was to assess predictors of inpatient mortality and one-year mortality in older Italians, hospitalized for dementia, heart failure, chronic obstructive pulmonary disease, stroke, hip fracture and myocardial infarction at the Verona Teaching Hospital, Northern Italy. Methods: At admission, 429 patients aged 65 years and older reported information on: sociodemographic characteristics, Barthel index at admission and two weeks before, and severity of investigated diagnosis; at discharge: diagnosis, comorbid conditions, complications from hospital records, drug therapy, and Barthel index. One year after discharge, an ad hoc questionnaire for those subjects found to have died on phone contact was administered to a proxy to collect data on new hospital admissions, onset of new conditions, need for formal care, a short version of the Barthel index one month before death, and the place of death. Results: Sex and specific diseases at admission were not significant predictors of inpatients, nor was one-year mortality in this cohort, whereas the presence of any comorbid conditions doubled the risk of mortality at one year compared with patients without comorbidity. Those patients who had moderate to severe/total dependency in ADL at admission were three times more likely to have died at discharge than those who were independent. The same risk for mortality at one-year follow-up was found in those patients who were severely or totally dependent at preadmission, at admission, or at discharge. Conclusions: Functional status and comorbidity are key risk factors for mortality in the elderly. Therefore, multidimensional assessment, including functional status prior to hospitalization should always be assessed, and should be considered a relevant predictor of short- and long-term outcomes.

Prevalence of vertebral fractures, vascular calcifications, and mortality in warfarin treated hemodialysis patients.

Warfarin inhibits vitamin-K dependent proteins involved in bone mineralization and the prevention of vascular calcification (bone Gla protein BGP, matrix Gla protein MGP). In this multicenter, cross-sectional study with 3-year follow-up, data from 387 patients on hemodialysis for ≥1 year at 18 dialysis units were analyzed. Patients on warfarin treatment for > 1 year (11.9% of the population) were compared with the remaining cohort for vertebral fractures, vascular calcifications and mortality. Vertebral fractures and vascular calcifications were sought in L-L vertebral X-rays (D5 to L4). Compared with controls, warfarin-treated male patients had more vertebral fractures (77.8 vs. 57.7%, p<0.04), but not females (42.1% vs. 48.4%, p=0.6); total BGP was significantly reduced (82.35 vs. 202 µg/L, p<0.0001), with lower levels in treated men (69.5 vs. women 117.0 µg/L, p=0.03). In multivariate logistic regression analyses, the use of warfarin was associated with increased odds of aortic (OR 2.58, p<0.001) and iliac calcifications (OR 2.86, p<0.001); identified confounders were age, atrial fibrillation, angina, PPI use and total BGP. Seventy-seven patients died during a 2.7±0.5 year follow-up. In univariate Cox regression analysis, patients on warfarin had a higher risk of all-cause mortality (HR 2.42, 95% CI 1.42-4.16, p=0.001) when compared with those untreated and data adjustment for confounders attenuated but confirmed the significant warfarin-mortality link (HR: 1.97, 95% CI: 1.02-3.84, P=0.046). In hemodialysis patients, additional studies are warranted to verify the risk/benefit ratio of warfarin, which appears to be associated with significant morbidity and increased mortality.

Gender Differences and Health Status in Old and Very Old Patients

OBJECTIVES To examine gender differences according to health status, social support, and DRG reimbursement in a population of elderly patients admitted to a hospital geriatric ward in Italy and also to examine the patterns of these differences across old age strata. DESIGN Observational study PARTICIPANTS A total of 2171 patients, 70 years and older (females = 1088), consecutively admitted for acute care to a geriatric ward in a general hospital during a 30-month period were included. Patients were stratified into 3 age groups: 70 to 79 (n = 1038, females = 521), 80 to 89 (n = 948, females = 476), and 90+ (n = 185, females = 91). MEASUREMENTS Demographics, main reason for hospitalization, Charlson Index, APACHE II score, APACHE II-APS subscore, serum albumin, number of currently administered drugs, cognitive status, depression, functional status, length of stay, Diagnoses Related Group (DRG) weight, in-hospital, and 3-month mortality were recorded. Differences were evaluated according to gender across old age strata. RESULTS In the group of 70- to 79-year-old patients, significant differences were found regarding number of comorbidities, biological and clinical markers of clinical severity (ie, serum albumin, APS, delirium), and functional status on admission (ie, the greater impairment was found in male patients, with a higher in-hospital and 3-month mortality). Moreover, females had less social support and more often live alone. DRG weight parallels clinical complexity, whereas length of stay is comparable. Gender differences were less evident in the 80-89 year-old patients and almost absent in those 90+. CONCLUSIONS Data indicate that on hospital admission gender differences are significant in young old patients, but not in old and very old, suggesting a poor survivorship of males with increasing age.

Hypoglycemia is independently associated with multidimensional impairment in elderly diabetic patients

Aim. To identify the characteristics associated with multidimensional impairment, evaluated through the Multidimensional Prognostic Index (MPI), a validated predictive tool for mortality derived from a standardized Comprehensive Geriatric Assessment (CGA), in a cohort of elderly diabetic patients treated with oral hypoglycemic drugs. Methods and Results. The study population consisted of 1342 diabetic patients consecutively enrolled in 57 diabetes centers distributed throughout Italy, within the Metabolic Study. Inclusion criteria were diagnosis of type 2 diabetes mellitus (DM), 65 years old or over, and treatment with oral antidiabetic medications. Data concerning DM duration, medications for DM taken during the 3-month period before inclusion in the study, number of hypoglycemic events, and complications of DM were collected. Multidimensional impairment was assessed using the MPI evaluating functional, cognitive, and nutritional status; risk of pressure sores; comorbidity; number of drugs taken; and cohabitation status. The mean age of participants was 73.3 ± 5.5 years, and the mean MPI score was 0.22 ± 0.13. Multivariate analysis showed that advanced age, female gender, hypoglycemic events, and hospitalization for glycemic decompensation were independently associated with a worse MPI score. Conclusion. Stratification of elderly diabetic patients using the MPI might help to identify those patients at highest risk who need better-tailored treatment.