Piera Barbisoni

Atrial fibrillation and cognitive disorders in older people

OBJECTIVES: To find a correlation between chronic non‐rheumatic atrial fibrillation (CNRAF) and cognitive impairment in a group of older, nondemented patients.

Dementia is a major predictor of death among the Italian elderly

To the Editor: We read with interest the article by Baldereschi et al. on the effect of dementia in predicting death among Italian elderly.1 We have pertinent data on 24 and 60 months’ mortality rate obtained in a multidimensional study conducted in Italy in 1992 on a community-dwelling population 70 years of age and older.2 All institutionalized subjects were excluded. At baseline (1992), valid questionnaires assessing demographics, mental status, chronic conditions, and functional and social status were available for 549 persons (89.6% of the eligible population). Vital status and time of death 2 (1994) and 5 years (1997) after the baseline evaluation was ascertained by telephoning patients and caregivers. The mean age of the 549 persons (179 men and 370 women) was 76.9 ± 5.4 years. They had 4.6 ± 2.0 years of education; they were affected by 3.5 …

Functional Trajectories During Hospitalization: A Prognostic Sign for Elderly Patients

BACKGROUND Clinicians have used measurements of pathological conditions and functional status to capture the heterogeneity of older individuals for prognostic purposes. However, the literature pays low attention to physical functional changes. METHODS A retrospective cohort study to investigate the association between functional changes during hospitalization and 3-month mortality. A total of 1,119 acutely ill elderly patients admitted to four beds arranged like a high-dependency area in a geriatric unit (mean age 80.6 +/- 7.8 years) were subdivided into four groups according to degree of functional decline at admission in comparison with the premorbid level and ability or inability to regain function at discharge: with moderate loss, able to regain (group a) and unable to regain function (group b); and with severe loss, able to regain (group c) and unable to regain function (group d) during hospitalization. Age, gender, cognitive and functional status (basic activities of daily living -[BADL]), serum albumin, Acute Physiology Score, Acute Physiology and Chronic Health Evaluation II score, comorbid conditions, number of drugs, and length of stay were collected. RESULTS Total 3-month mortality was 17.9%. Mortality rate was 10.7%, 17.6%, 14.5%, and 36.7% in groups a, b, c, and d, respectively. In three different multivariate Cox models including BADLs before admission, at admission, and at discharge, inability to regain function during hospitalization was an independent factor associated with 3-month mortality. CONCLUSIONS In acutely ill elderly patients, lack of function regain during hospitalization is associated with higher mortality rate at 3 months, compared with those capable to regain the baseline functional status.

Mood improvement in elderly women after in-hospital physical rehabilitation

OBJECTIVE To evaluate the relationship between change in depressive symptoms and in-hospital physical rehabilitation in elderly women. DESIGN Longitudinal study. SETTING Hospital facility (geriatric evaluation and rehabilitation unit). PATIENTS One hundred twenty-three elderly inpatient women (mean age: 78.4+/-6.9 years, range 60 to 93) with good cognitive status (Mini Mental State Examination: 23.1+/-5.1) consecutively admitted over a 7-month period. INTERVENTION Physical therapy tailored to individual needs (five sessions a week of 30 to 45 minutes each). MAIN OUTCOMES MEASURES On admission: cognition (MMSE), depressive symptoms (Geriatric Depression Scale [GDS]), functional status (basic and instrumental activities of daily living [BADL, IADL], Tinetti scale), and somatic health. On discharge: depressive symptoms and gait and balance performances (Tinetti scale). RESULTS Seventy-five patients (61%) did not show changes on Tinetti scale over the hospitalization period and 48(39%) had a change of 3 or more points. Nonresponders had no change of GDS over the hospitalization period for all levels of physical disability on admission, whereas responders had relevant improvement of depressive symptoms when markedly disabled on admission, and progressively smaller improvements of depressive symptoms with increasing function on admission. CONCLUSIONS The study provides evidence that mood status changes synchronically with disability.

The management of adverse clinical events in nursing homes : A 1-year survey study

OBJECTIVE: In Italian nursing homes (NHs), care delivery at night and during holidays is not regulated by regional laws; some facilities employ staff physicians, others employ physicians engaged from year to year (temporary physicians), and others employ publicly funded National Health System (NHS) physicians. This study was designed to determine whether the use of different kinds of physicians leads to different outcomes with regard to the rate of hospitalization and appropriateness of the management of adverse clinical events.

DEMENTIA DOES NOT PREVENT THE RESTORATION OF SAFE GAIT AFTER HIP FRACTURE

To the Editor: We read with interest the study of the relationship between gait changes and falls by Brian Maki, PhD, and his colleagues.’ Maki finds that subtle changes in stride-tostride variability are important predictors of falls while other gait variables thought to be altered in fallers (e.g., walking speed and the average values of different temporal and spatial measures) are not. We have results that support these findings and suggest that in other instances as well, the most sensitive measure of walking is variability and not the speed or (average) time spent in different phases of the gait cycle. Our findings also shed light on possible mechanisms for increased variability and its reversibility in certain older populations. Using an ankle-worn footswitch system, we measured the stride-to-stride variability of the gait cycle (stride time) and its subdivisions (e.g., swing time) during a 6-minute, self-paced walk in a group of relatively healthy, communityliving, older men and women.2 When subjects were stratified based on fall history, all measures of gait variability were significantly larger in the fallers compared with the nonfallers ( P < .0002). Subjects in this study walked almost 60% faster, on average, than the subjects in Maki’s study (0.7 dsec) , possibly indicating a higher level of mobility. Nevertheless, even in these subjects, we observed the discriminatory ability of gait variability measures. Again, however, speed and average values were not different in the fallers and non-fallers (e.g., speed was 1.13 d s e c in both fallers and non-fallers). Maki speculates that the increased stride-to-stride variability in older fallers is a manifestation of impaired motor control. We studied subjects with Huntington’s disease and Parkinson’s disease, as well as controls, and found that all measures of gait instability were increased significantly in the neurological subjects compared with controls. However, walking rate and the time spent in many phases of the gait cycle were similar in the three groups. This suggests that central nervous system deficits such as those seen in Huntington’s disease can produce increased stride-to-stride variability without altering the timing of the average gait cycle. We have observed similar gait changes in subjects with heart f a i l ~ r e , ~ suggesting that central cardiovascular effects and/or peripheral weakness may also be responsible for increased variability. Maki questions whether variability in gait is amenable to change, perhaps through interventions such as balance or gait training, changes in footwear, or use of assistive devices. We hypothesized that certain physiological changes common in older people may give rise to increased gait variability and that partial reversal of these processes through exercise should help reduce gait variability. To test this hypothesis, we have been measuring stride-to-stride variability in community-living older women selected for their impaired mobility before and after 6 months of aerobic and progressive resistance muscle training. We have now examined the gait variability of five exercisers. After the exercise program, leg press one repetition maximum increased by 14%, muscle endurance by 130%, and maximal aerobic capacity by 30%. Preliminary analysis shows no change in habitual gait speed. In contrast, gait instability, as measured by the stride interval coefficient variation, was reduced by an average of 40%. Apparently, gait variability is modifiable, at least in certain populations. These findings all support the idea that the mechanisms responsible for gait instability are, to some degree, distinct from those that control walking speed and timing. In the case of some older fallers, stride-to-stride stability is significantly diminished, but speed and gait cycle timing are unchanged. We therefore agree with Maki and encourage further research on the clinical utility and mechanisms behind increased stride-to-stride variability.

WHO ARE THE OLDER PATIENTS FAILING TO RECOVER MOBILITY AFTER REHABILITATION

To the Editor: We take the issue of duplicate publication of data very seriously and, therefore, were quite concerned when we learned that some readers had contacted theJourna1 of the American Geriatrics Society about the possibility that our two recent publications may be characterized as duplicative. This is not so. The appearance of the article in this journal shortly after the publication of our article in Medical Care makes it seem that the two were submitted simultaneously. This, indeed, would be duplicative because the article in this journal that focuses on the 16-month data includes the 8-month data presented in the Medical Care article. In fact, however, the first article was accepted for publication in Medical Care before we undertook the data analysis for the Journal article and 6 months before its submission to the Journal. Unfortunately, an unexpected editorial delay postponed the publication of the Medical Care article from its original proposed publication date of March 1995 to June 1996, thus leading to the appearance of possible joint publication.

Assessment of functional ability with the bed rise difficulty scale in a group of elderly patients.

The aim of the study (part of the Progetto Longitudinale Gussago) was to evaluate the variables related to the difficulty in rising from a bed in 2 groups of elderly patients: nursing home residents, and patients admitted to a geriatric evaluation and management unit. Functional ability was tested through the bed rise difficulty scale (BRD). The version used in this study considered only those 7 items (out of 12) found to be of value. Only those patients who were able to rise from bed without help were selected in order to achieve the aim of the study (33 males, 113 females; mean age 79.6 +/- 7.3 years). Although the 146 patients assessed were considered as having a good functional level (Tinetti score 18.8 +/- 6.9, ADL Katz score 1.6 +/- 1.4), most of them had high scores on the BRD scale, indicating the ability of this scale to detect early, mild disability. The total score of the BRD scale was significantly related to the ADL Katz (r = 0.29, p = 0.000), Tinetti scale (r = -0.39, p = 0.000) and physical performance test (PTT; r = -0.47, p = 0.000). Similar results were obtained for the correlation between BRD time and ADL Katz (r = 0.033, p = 0.000), Tinetti scale (r = -0.30, p = 0.000) and PPT-(r = -0.46, p = 0.000). In a logistic regression analysis the items of the PPT scale considering upper extremity function and Tinetti balance score were significantly associated with the total bed rise time and score.

FUNCTIONAL AND BIOMEDICAL COMPONENTS IN THE MEASURES OF DISEASE SEVERITY IN OLDER PEOPLE

To the Editor: We have read with interest the paper by Parmelee et al., “Validation of the Cumulative Illness Rating Scale in a Geriatric Residential Population,” recently published on the journal.’ The authors conclude that the CIRS appears to be a valid indicator because it distinguishes health status from functional disability, assuming that these conditions are not interchangeable. On the contrary, our impression is that CIRS gives too much emphasis to function, in this way disregarding the assumption that clinical problems have effects on general health which are, at least partially, independent from disabililty. We propose a different methodology, which is less linked to functional parameters while at the same time is able to capture the effects of disease severity on general health. We report here data obtained utilizing the physiological dimension of clinical problems measured by Greenfield’s Index of Disease Severity-IDS, in which illness severity is scored independently by its impact on function.’ This index assigns a score (0-4) to absence of disease (0): asymptomatic disease ( I ) , symptomatic disease controlled by therapy (2), symptomatic disease uncontrolled by therapy (3), life-threatening disease or the greatest severity achievable by the disease (4). In the definition of our Burden of Disease (BOD) index, based on the average of the 15 items, we considered the following diseases: heart diseases (ischemic and organic), primary arrhythmias, nonischemic congestive heart diseases, hypertension, peripheral vascular diseases, chronic lung diseases, gastrointestinal diseases, hepatic diseases, chronic kidney diseases, muscoloskeletal diseases, stroke, Parkinson’s disease, anemia, diabetes mellitus, and tumors. Psychiatric and behavioral diseases are considered separately. We assessed the 357 older patients (256 females) admitted consecutively to our Geriatric Ward during the period August 15, 1993 to December 1994, on demographic, functional and clinical variables. Means (SD) were age (years = 78.9 (7.3); Mini-Mental State Examination = 21.7 (6.3); Geriatric Depression Scale = 13.7 (6.9); BADL (functions lost) = 2.6 (1.9); IADL (functions lost) = 4.8 (2.6); Tinetti scale = 15.9 (9.2); PPT = 12.0 (6.4); diseases (n) = 4.9 (1.7); drugs (n) = 5.1 (1.8). Means and standard deviations for each clinical problem, the BOD index value, and percent reporting moderate (IDS = 2) or greater impairment of IDS items are reported in the table. As recommended by Parmelee et al., we correlated the results with functional and clinical laboratory data to support the validity of the BOD index. The BOD index seems to be a reliable instrument to detect the correlation between the burden of diseases, function, and parameters of biomedical relevance. In particular, Pearson’s Y for the BOD index and ADL, IADL, Tinetti scale, and Physical Performance Test is, respectively, 0.24 (P = .001), 0.14 ( P = .008), -0.26 ( P = .001), -0.28 (P = .001); for albumin, creatinine, and hemoglobin values are -0.12 (P = 0.022), 0.31 (P = 0.001), and -0.09 (P = 0.081), respectively. Our BOD index, although constructed in such a way that fewer functional parameters are involved, with CIRS, is able Table 1. Means, Standard Deviation, and Percent Reporting Moderate (IDS = 2) or Greater Impairment of Different IDS Items

P4-143: Dementia and mortality in elderly patients with low respiratory infections

Background: Low respiratory infections (LRI) are common in patients with dementia, and account for two thirds of deaths in this population. Prognosis, including long-term mortality, is important because lack of knowledge could foster underuse of palliative care services for those who would benefit and overuse of aggressive therapies for those who are unlikely to recover. Aim of the study is to investigate the association between LRI and three-month mortality in elderly patients with and without dementia. Methods: In a retrospective study 3300 newly admitted to our Sub-Intensive Care Unit, were selected and subdivided in 4 groups: 2566 patients without LRI and dementia, 265 with LRI and without dementia, 345 without LRI and with dementia, and 124 with LRI and dementia. Measurements were: age, gender, Barthel Index detected 2 weeks before admission and on admission, APACHE-II, Charlson Index, were assessed. Cognitive impairment was evaluated with MMSE and severe dementia as MMSE 12. LRI was diagnosed by clinical signs and chest radiography and treatment done according to the American Thoracic Society guidelines.