Pierugo Carbonin

Randomised trial of impact of model of integrated care and case management for older people living in the community

Abstract Objective: To evaluate the impact of a programme of integrated social and medical care among frail elderly people living in the community. Design: Randomised study with 1 year follow up. Setting: Town in northern Italy (Rovereto). Subjects: 200 older people already receiving conventional community care services. Intervention: Random allocation to an intervention group receiving integrated social and medical care and case management or to a control group receiving conventional care. Main outcome measures: Admission to an institution, use and costs of health services, variations in functional status. Results: Survival analysis showed that admission to hospital or nursing home in the intervention group occurred later and was less common than in controls (hazard ratio 0.69; 95% confidence interval 0.53 to 0.91). Health services were used to the same extent, but control subjects received more frequent home visits by general practitioners. In the intervention group the estimated financial savings were in the order of £1125 (

Is Age an Independent Risk Factor of Adverse Drug Reactions in Hospitalized Medical Patients

1800) per year of follow up. The intervention group had improved physical function (activities of daily living score improved by 5.1% v 13.0% loss in controls; P<0.001). Decline of cognitive status (measured by the short portable mental status questionnaire) was also reduced (3.8% v 9.4%; P<0.05). Conclusion: Integrated social and medical care with case management programmes may provide a cost effective approach to reduce admission to institutions and functional decline in older people living in the community. Key messages Responsibility for management of care of elderly people living in the community is poorly defined Integration of medical and social services together with care management programmes would improve such care in the community In a comparison of this option with a traditional and fragmented model of community care the integrated care approach reduced admission to institutions and functional decline in frail elderly people living in the community and also reduced costs

Long-Term Survival and Use of Antihypertensive Medications in Older Persons

Objective: To study the incidence and the risk factors of adverse drug reactions.

The effects of cognitive impairment on mortality among hospitalized patients with heart failure

OBJECTIVE: To determine whether older persons with hypertension who use specific calcium antagonists and ACE inhibitors have a different risk of mortality than those using β‐blockers.

Do calcium channel blockers increase the risk of cancer

PURPOSE Cognitive impairment is a common, potentially reversible condition among older patients with heart failure. Because cerebral metabolic abnormalities have been associated with reduced survival in younger patients with advanced heart failure, we assessed the effect of cognitive impairment on the survival of older patients with heart failure. METHODS The association between cognitive dysfunction and in-hospital mortality was assessed in 1113 patients (mean [+/- SD] age, 78 +/- 9 years) who had been admitted for heart failure to 81 hospitals throughout Italy. One-year mortality was assessed in 968 patients with heart failure (age, 76 +/- 10 years) participating in the same study. Cognitive impairment was defined as a Hodkinson Abbreviated Mental Test score <7. RESULTS In-hospital death occurred in 65 (18%) of the 357 participants with cognitive impairment and in 26 (3%) of the 756 patients with normal cognition (P <0.0001). Out-of-hospital mortality was 27% (51/191) among patients with cognitive impairment and 15% (115/777) among other participants (P <0.0001). In multivariate Cox regression models, decreasing levels of cognitive functioning were associated with increasing in-hospital mortality; cognitive impairment was associated with an almost fivefold increase in mortality (relative risk = 4.9; 95% confidence interval: 2.9 to 8.3) after adjusting for several potential confounders. CONCLUSION Cognitive impairment is an independent prognostic marker in older patients with heart failure. Assessment of cognitive functioning, even by simple screening tests, should be part of the routine assessment of elderly patients with heart failure.

Risk of gastrointestinal haemorrhage with calcium antagonists in hypertensive persons over 67 years old

Calcium channel blockers can block calcium signals that trigger cell differentiation and apoptosis, which are important mechanisms of cancer growth regulation. To ascertain whether calcium channel blocker use was associated with an increased risk of cancer, 750 hypertensive persons age > or = 71 years, with no history of cancer at baseline, were followed from 1988 through 1992. The patients were using either beta-blockers, angiotensin converting enzyme inhibitors or calcium channel blockers (verapamil, nifedipine, and diltiazem; mainly of the short-acting variety). Compared to beta-blockers (n = 424, 28 events), after adjusting for age, gender, race, smoking, body mass index, and number of hospital admissions not related with cancer, the relative risks of cancer (95% confidence interval) for angiotensin converting enzyme inhibitors (n = 124, 6 events) and calcium channel blockers (n = 202, 27 events) were 0.73 (0.30 to 1.78) and 2.02 (1.16 to 3.54), respectively. These findings indicate that calcium channel blocker therapy might increase the risk of cancer. New data are needed in patients using modern calcium channel blocker agents with more gradual absorption. This report should encourage further study of cancer outcomes in elderly patients who are vulnerable to cancer and who are receiving calcium channel blockers.

Body mass index and mortality among older people living in the community.

BACKGROUND Calcium antagonists are used frequently in management of hypertension. In addition to their cardiovascular effects, these drugs inhibit platelet aggregation. Therefore we examined whether the use of calcium antagonists was associated with an increased risk of gastrointestinal haemorrhage (GIH). METHODS A prospective cohort study was conducted from 1985 through 1992 on 1636 hypertensive persons aged > or = 68 years living in three communities. The participants were taking beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, or calcium antagonists; those taking combinations of these drugs were excluded. The incidence of GIH was assessed by surveying hospital discharge diagnoses and deaths. Age, gender, disability, arterial pressure, other drugs, and comorbid conditions were examined as confounders. FINDINGS Compared with beta-blockers (4819 person-years, 65 events), after adjustment for confounders the relative risk for GIH associated with ACE inhibitor (772 person-years, 13 events) was 1.23 (95% CI 0.66-2.28) and with calcium antagonists (1510 person-years, 42 events) it was 1.86 (1.22-2.82). The risks for verapamil, diltiazem, and nifedipine did not differ significantly. The results were unchanged when the analyses were restricted to severe events (GIH in conjunction with blood transfusion or death). INTERPRETATION Calcium antagonists were associated with an increased risk of GIH in this population. Therefore caution is needed in prescription of these agents to old patients who have other risk factors for gastrointestinal bleeding.

Enalapril prevents cardiac fibrosis and arrhythmias in hypertensive rats

OBJECTIVES: To determine if body mass index (BMI = weight/height2), predictive of mortality in seriously ill hospitalized and institutionalized patients, is also predictive of mortality in a longitudinal epidemiologic study.

Impact of Integrated Home Care Services on Hospital Use

To evaluate the effects of hypertension on cardiac hypertrophy, on myocardial structure, and on ventricular arrhythmias, 27 3-month-old spontaneously hypertensive rats were treated with enalapril (10 ing/kg) daily for 11 months and compared with 26 untreated control rats. Systolic arterial pressure was significantly decreased in treated rats, and at the end of the experiment, it was 199±3 mm Hg (treated) versus 237±3 mm Hg (controls) (p<0.001). At this time, spontaneous arrhythmias and induced arrhythmias either by programmed electrical stimulation (train of stimuli +1 or 2 extrastimuli) or by trains of eight stimuli at decreasing coupling intervals were observed in isolated heart preparations. Comparing enalapril-treated and control rats, spontaneous arrhythmias (9 of 27 versus 20 of 26, respectively, p<0.01), programmed stimulation-induced arrhythmias (3 of 26 versus 12 of 23, respectively; p<0.01), and trains of stimuli-induced arrhythmias (4 of 26 versus 14 of 19, respectively, p< 0.001) were less frequent in the enalapril group. Left ventricular weight was decreased in treated rats by 18% (p<0.001). Enalapril administration diminished the fraction of myocardium occupied by foci of replacement fibrosis normally occurring in control rats by 59% (/?< 0.001). Finally, a significant correlation was found between left ventricular weight, the extent of myocardial fibrosis, and the occurrence of ventricular fibrillation. It was concluded that chronic treatment with enalapril, which resulted in attenuation of systemic arterial pressure by limiting cardiac hypertrophy and myocardial fibrosis, decreases the propensity of the heart of hypertensive rats to arrhythmogenesis.

Nutritional Assessment: A Primary Component of Multidimensional Geriatric Assessment in the Acute Care Setting

OBJECTIVE: To examine the effect of a home care program based on comprehensive geriatric assessment and case management on hospital use and costs among frail older individuals.