Massimiliano Massaia

Predictive Factors of In‐Hospital Mortality in Older Patients Admitted to a Medical Intensive Care Unit

OBJECTIVES: To identify prognostic factors that are independently predictive of in‐hospital mortality in older patients hospitalized in a medical intensive care unit (MICU).

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.

Home hospitalization service for acute uncomplicated first ischemic stroke in elderly patients: a randomized trial.

Objectives: To evaluate whether home treatment of elderly patients with acute uncomplicated first ischemic stroke is associated with different mortality rates and clinical outcomes from those of patients treated on a general medical ward (GMW).

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.

Efficacy of oxycodone/acetaminophen and codeine/acetaminophen vs. conventional therapy in elderly women with persistent, moderate to severe osteoarthritis-related pain

We aimed to evaluate the efficacy and safety of oxycodone/acetaminophen (O/A) and codeine/acetaminophen (C/A) vs. conventional therapy (CT) without opioids in older women suffering from osteoarthritis (OA)-related pain, sub-optimally responsive to prior conventional treatments. We performed a 6 week, randomized, single blind, controlled study in three nursing homes. We enrolled 154 women with painful OA. They were assigned to treatment with O/A (n=52) and C/A (n=52) vs. CT (n=50). We evaluated at baseline and at week 6: average pain in the last week (mean pain, MeP), pain at rest (RP), pain in movement (MP) (numeric rating scale, NRS); depressive symptoms (Beck Depression Inventory-II, BDI-II); functional status (activities of daily living, ADL) and cognitive status (mini mental state evaluation, MMSE). We considered the adverse events (AEs) in the study period. At week 6, MeP, RP and MP were significantly reduced in all three groups (p<0.001); compared to CT, O/A and C/A were associated with greater reductions in MeP (p<0.001 and p=0.004, respectively), in RP (p=0.028 and p=0.032, respectively) in MP (p<0.001 and p=0.002, respectively) and with significant improvement in BDI-II score (p=0.05 and p=0.04, respectively) and ADL value (p=0.04 and p=0.05, respectively). AE rates did not differ between groups.

White-coat effect among older patients with suspected cognitive impairment: prevalence and clinical implications

OBJECTIVES To evaluate the prevalence of white-coat effect (WCE), and its association with individual anxiety and insight of disease, among older patients evaluated for suspected cognitive impairment. METHODS This prospective cohort study, conducted in an Alzheimer Evaluation Unit, involved patients aged 55 years or older with suspected cognitive impairment. WCE was defined as a difference of at least 20 mmHg in systolic or 10 mmHg in diastolic blood pressure (BP) measured either by a physician during the visit or by a nurse (before and after the visit), compared with home self-blood pressure measurement (SBPM). Severity of cognitive impairment was evaluated through the Mini-Mental State Examination (MMSE); the Clinical Insight Rating Scale (CIR) and the Guidelines for the Rating for Awareness Deficits (GRAD) were used to evaluate the subjects insight; anxiety disorder was evaluated using the seven-question Generalized Anxiety Disorder scale (GAD-7). RESULTS Among 273 subjects, prevalence of WCE was 52%, 32.6% and 30.4%, according to physician and nurse BP measurements, respectively (p = 0.000). Prevalence of WCE did not differ between patients diagnosed with and without dementia, but was higher among patients with than in those without anxiety disorder (70.7% vs 38.2%, p = 0.000). Positive relations were observed between severity of anxiety and insight of disease, which were both inversely related with severity of cognitive impairment. CONCLUSIONS WCE is extremely common and is correlated to individual anxiety and insight of disease among older outpatients with suspected cognitive impairment; overestimation of hypertension severity might lead to unnecessary drug treatment and greater health costs in this setting.To evaluate the prevalence of white‐coat effect (WCE), and its association with individual anxiety and insight of disease, among older patients evaluated for suspected cognitive impairment.

MINI-MENTAL STATE EXAMINATION AND WECHSLER MEMORY SCALE SUBTEST OF LOGICAL MEMORY: CORRELATION IN AN OVER 70-YEAR-OLD POPULATION

Summary The correlation between the mini-mental state examination (MMSE) and the logical memory (LM) subtest of the Wechsler memory scale (WMS) was evaluated in a group of healthy Italians, aged seventy and over, with no significant cognitive impairment. A horizontal study was carried out using 146 subjects (126 women and 20 men; mean age 72.7 ±3.7 years) who enrolled consecutively in the exercise courses for the elderly organized by the Municipality of Torino. A statistically significant correlation was found between the average total MMSE score and the LM score (r = 0.4315, p

Prevalence and Clinical Implications of Orthostatic Hypotension in Elderly Inpatients

Background: Prevalence of orthostatic hypotension (OH) has been investigated in many studies, mainly on selected samples of subjects. We aimed to assess the prevalence of OH and its association with incidence of adverse events among older medical inpatients. Methods: OH was evaluated according to current guidelines at admission and at discharge among older medical inpatients admitted to a Geriatric acute ward of an university-teaching hospital. A comprehensive clinical (CIRS, Cumulative Illness Rating Scale), functional (ADL, Activities of Daily Living; IADL, Instrumental Activities of Daily Living Scale, TUG, Timed Up and Go) and cognitive (SPMSQ, Short Portable Mental Status Questionnaire) evaluation was performed. Length of stay-in and adverse events (death, institutionalization, falls, syncope, posttraumatic fractures, cardiovascular events) were evaluated at discharge and at 6 months. Results: Among 343 patients admitted, 195 (mean age 80.1 ± 7.2) were enrolled. Prevalence of OH at admission was 52.3%; patients with OH had higher systolic and diastolic blood pressure values (p=0.001 both) and lower heart rate (p=0.02) than patients without OH. Although several conditions were associated with presence of OH, only history of neurological and coronary artery disease were slightly independently associated with OH (p=0.03 and p=0.02, respectively). Prevalence of OH at discharge was 49%. OH was not significantly associated with any adverse event, nor during the hospital stay nor after discharge. Conclusion: OH is extremely common among elderly inpatients, but it was not associated with adverse events. Our results question the utility of routinely screening older medical inpatients for OH.

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