Clinical Implications of Potentially Inappropriate Prescribing According to STOPP/START Version 2 Criteria in Older Polymorbid Patients Discharged From Geriatric and Internal Medicine Wards: A Prospective Observational Multicenter Study.

OBJECTIVES: To evaluate whether STOPP/START v2 potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs) are associated with 6-month mortality and unplanned hospitalization in hospital-discharged older patients. DESIGN: Multicenter prospective cohort observational study. SETTING AND PARTICIPANTS: Patients aged ≥65 years consecutively discharged from acute geriatric and internal medicine wards of 2 teaching hospitals in northwestern Italy. METHODS: At discharge, a comprehensive geriatric assessment was performed in each patient, prescribed medications were recorded, and PIMs and PPOs were determined according to STOPP/START v2. Death and unplanned readmissions at 6 months were investigated through telephone interviews; variables associated with outcomes were identified in the overall sample and according to discharge setting [ie, home vs medium/long-term care facility (MLTCF)] through a multivariate logistic regression model. RESULTS: Among 611 patients (mean age 81.6 years, 48.4% females, 34.2% MLTCF-discharged, mean number of drugs 7.7 ± 3.2) with a potentially inappropriate prescription (PIP) prevalence at discharge of 71.7% (PIMs 54.8%, PPOs 47.3%), mortality and unplanned readmission rates were 25.0% and 30.9%. Neither PIMs nor PPOs were associated with overall mortality. A higher number of PIMs was significantly associated with unplanned readmission in the overall sample [odds ratio (OR) 1.23, 95% confidence interval (CI) 1.03-1.46] and in home-discharged patients (OR 1.38, 95% CI 1.13-1.68). The number of drugs at discharge was associated with unplanned readmissions in the overall sample (OR 1.11, 95% CI 1.05-1.18) and in MLTCF-discharged patients (OR 1.27, 95% CI 1.13-1.42). PPOs were not significantly associated with clinical outcomes. CONCLUSIONS/IMPLICATIONS: In hospital-discharged older patients with polymorbidity, 6-month unplanned readmissions were associated with a higher number of PIMs in home-discharged patients and with number of drugs in MLTCF-discharged patients. This reaffirms the importance of performing a systematic and careful review of medication appropriateness in hospital-discharged older patients.

Prevalence and predictors of inappropriate prescribing according to the Screening Tool of Older People's Prescriptions and Screening Tool to Alert to Right Treatment version 2 criteria in older patients discharged from geriatric and internal medicine wards: A prospective observational multicenter study.

AIM: To evaluate the prevalence and predictors of potentially inappropriate medications (PIM) and potential prescribing omissions (PPO) in hospital-discharged older patients, according to the recently updated Screening Tool of Older People's Prescriptions and Screening Tool to Alert to Right Treatment version 2 criteria. METHODS: This was a multicenter prospective observational study of patients aged ≥65 years consecutively discharged from geriatric and internal medicine wards. Each patient underwent a comprehensive geriatric assessment, and PIM and PPO at discharge were determined according to the Screening Tool of Older People's Prescriptions and Screening Tool to Alert to Right Treatment version 2 criteria. A multivariate logistic regression was carried out to identify variables independently associated with PIM and PPO. RESULTS: Among 726 participants (mean age 81.5 years, 47.8% women), the prevalence of PIM and PPO were 54.4% and 44.5%, respectively. Benzodiazepines and proton-pump inhibitors were the drugs most frequently involved with PIM, whereas PPO were often related to 5-alpha reductase inhibitors, angiotensin-converting enzyme inhibitors, statins and drugs for osteoporosis. The number of medications (OR 1.22, 95% CI 1.15-1.28) and discharge from geriatric units (OR 0.55, 95% CI 0.40-0.75) were associated with PIM, whereas PPO were independently associated with discharge from geriatric wards (OR 0.44, 95% CI 0.31-0.62), age (OR 1.04, 95% CI 1.02-1.07), comorbidities (OR 1.17, 95% CI 1.04-1.30) and the number of drugs (OR 1.12, 95% CI 1.05-1.18). CONCLUSIONS: Inappropriate prescribing is highly prevalent among hospital-discharged older patients, and is associated with polypharmacy and discharge from internal medicine departments. Geriatr Gerontol Int 2019; 19: 5-11.

Prevalence, predictors and clinical impact of potentially inappropriate prescriptions in hospital-discharged older patients: A prospective study.

AIM: Potentially inappropriate prescriptions (PIP) have been highly reported in older patients, but few studies have investigated their association with adverse clinical outcomes. The present study aimed to evaluate the prevalence and predictors of PIP in hospital-discharged older adults, and to explore the association of PIP with death and rehospitalization. METHODS: We carried out a multicenter prospective cohort study on hospital-discharged patients aged ≥65 years. Each patient underwent a comprehensive geriatric assessment, and the prevalence of PIP was obtained by applying Beers Criteria 2015 to discharge documents. Telephone follow up was carried out at 6 months. RESULTS: The prevalence of PIP was 63%, and was associated with psychiatric-behavioral disorders (OR 1.64), the number of daily taken medications (OR 1.08) and long-term care discharge (OR 1.91), whereas better functional performance was protective (OR 0.93). Neither the presence nor the number of PIP were associated with rehospitalization or mortality at 6 months. However, insulin sliding scale (OR 4.97) and use of drugs inappropriate in heart failure (OR 4.64) were associated with an increased risk of rehospitalization, whereas prescription of digoxin ≥0.125 mg/daily (OR 1.77) and antipsychotics (OR 1.65) were associated with a higher risk of mortality. CONCLUSIONS: Among older hospital-discharged patients, we documented a high prevalence of PIP that was significantly associated with polytherapy, the presence of psychiatric-behavioral disorders and discharge to long-term care facilities. Although the presence and the number of PIP were not associated with adverse outcomes, some specific inappropriate prescriptions were associated with a higher risk of hospital readmission and death. Geriatr Gerontol Int 2018; 18: 561-568.

Length of Stay in the Emergency Department and Occurrence of Delirium in Older Medical Patients.

OBJECTIVES: To determine whether emergency department (ED) length of stay before ward admission is associated with incident delirium in older adults. DESIGN: Prospective cohort study. SETTING: Hospital. PARTICIPANTS: Individuals aged 75 and older without delirium at ED entry, coma, aphasia, stroke, language barrier, psychiatric disorder, or alcohol abuse (N = 330). MEASUREMENTS: On ED admission, individuals underwent standardized evaluation of comorbidity (Cumulative Illness Rating Scale), cognitive impairment (Short Portable Mental Status Questionnaire), functional independence (activities of daily living, instrumental activities of daily living), pain (Numeric Rating Scale), and acute clinical conditions (Acute Physiology and Chronic Health Evaluation II). During the first 3 days after ward admission, the presence of delirium (defined as ≥1 delirium episodes within 72 hours) was assessed daily using a rapid assessment for delirium (4AT scale). ED length of stay was calculated as the time (hours) between ED registration and when the person left the ED. RESULTS: ED length of stay longer than 10 hours (odds ratio (OR) = 2.23, 95% confidence interval (CI) = 1.13-4.41), moderate to severe cognitive impairment (OR = 5.47, 95% CI = 2.76-10.85), and older age (OR = 1.07, 95% CI = 1.01-1.13) were associated with delirium onset. CONCLUSION: ED length of stay longer than 10 hours was associated with greater risk of delirium in hospitalized older adults, after adjusting for age and cognitive impairment.

Nonlinear analysis of electroencephalogram in frontotemporal lobar degeneration.

Frontotemporal lobar degeneration (FTLD) is a form of dementia characterized by a profound alteration in personality and social behavior and is associated with atrophy in the frontal and temporal brain regions. Despite recent advances, diagnosis of FTLD remains challenging. In the last decade, different studies have combined EEG analysis with mathematical models and theories that consider EEG signals as the result of nonlinear chaotic activity. The aim of the present study was to determine whether new nonlinear dynamic analysis can provide useful information on brain activity in FTLD patients. 19-lead EEG was recorded in patients with clinical diagnosis of FTLD and in healthy controls under two different conditions: closed eyes and open eyes. A nonlinear measure of complexity, correlation dimension (D2), was calculated. Our results show an increase in D2 in healthy individuals when the eyes are open, in keeping with an increase in information processing. Conversely, in FTLD patients, no increase in D2 occurred in the open eyes condition, and D2 was significantly lower than that observed in controls. Our results suggest that the dynamic processes underlying the EEG are less chaotic and complex in FTLD patients compared with normal individuals, thus providing important information on both brain functioning and possible clinical diagnostic applications.

[Taking care of the caregiver: evaluation of the degree of satisfaction, stress levels and expectations of caregivers of patients attending an ambulatory unit for Alzheimer disease evaluation]. / Prendersi cura del caregiver: valutazione del grado di soddisfacimento, dello stress e delle aspettative di caregiver afferenti ad un ambulatorio Unità di Valutazione Alzheimer.

According to literature, challenges associated with caregiving of demented should be taken into great consideration. The aim of the present study was to evaluate the knowledge about dementia and health services dedicated to demented care among the caregivers of the patients attending our Dementia Ambulatory, caregivers' level of autonomy in taking care of the demented patients, their levels of stress and the degree of their satisfaction as the services provided by our Dementia Ambulatory. Our data show how a memory clinic needs to take care of both patients and their caregivers, with particular stress on caregiver specific education and well-being.

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 Alzheimer's 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.

Stress in professional care-givers working with patients with dementia: a hypothesis-generating study.

BACKGROUND AND AIMS: Caregiving can be extremely stressful, especially when patients' ability to communicate is impaired. While the stress undergone by relatives assisting their loved ones has been widely investigated, fewer data can be found about the stress in healthcare professionals. The aim of this study is to evaluate whether a specific training course could be related to a reduction in the levels of stress of professional care-givers working with patients suffering from dementia. METHODS: Work-related levels of stress of study participants were evaluated with the Staff Stress Measure Dementia Care Scale, at baseline and four months after completion of an eight-month training course. RESULTS: We found no significant correlation between care-givers' age, gender, marital status, years of employment or perceived economic status, and their stress levels at baseline. Patients' characteristics were not related with care-givers' stress at baseline. The mean level of stress was significantly reduced (34.64±4.15 vs 26.64±3.82, p<0.001) between baseline and the study endpoint. CONCLUSIONS: Increased knowledge of management of patients affected by dementia could help professional care-givers to reduce their work-related stress. Our results add to the evidence of the benefit of personnel support in reducing levels of stress at work.

Pro-inflammatory cytokine genes influence the clinical features of frontotemporal lobar degeneration.

BACKGROUND/AIMS: Recent studies suggested a role for pro-inflammatory mediators in frontotemporal lobar degeneration (FTLD). The objective of this study was to evaluate the association of functionally active polymorphisms in pro-inflammatory cytokine genes with the occurrence and the clinical features of the disease. METHODS: Using a case-control study, we compared allelic and genotypic frequencies of several polymorphisms in the interleukin (IL)-1alpha, interleukin (IL)-1beta, interleukin (IL)-6 and tumor necrosis factor (TNF)-alpha genes between 110 FTLD patients and 119 healthy controls. RESULTS: No significant association between the examined polymorphisms and the disease was found. However, in comparison with remaining genotypes, patients carrying the T/T genotype of the IL-1beta gene showed a significantly lower age at onset of the disease. In addition, scores of the Frontal Assessment Battery were significantly modified by the IL-6 -174G>C polymorphism. CONCLUSION: Our findings support a role for pro-inflammatory cytokine genes in the pathogenesis of frontotemporal lobar degeneration.

Dehydroepiandrosterone sulfate (DHEA-S) and Alzheimer's dementia in older subjects.

OBJECTIVES AND METHODS: We investigated the association of serum dehydroepiandrosterone sulfate (DHEA-S) levels with dementia of Alzheimer's type (DAT) and impairment in selected cognitive domains (memory, language, attention and working memory) in 158 patients (75.5+/-6.7 years, 46 men) with first-diagnosed probable DAT and in 158 age- and sex-matched controls. As secondary goal, we evaluated whether DHEA-S baseline levels were associated with cumulative 6-year mortality. RESULTS: A negative correlation between DHEA-S levels and age was observed (R=-0.25, p<0.001). Age-stratified analysis did not show significant differences of DHEA-S levels between DAT patients and controls. No significant association was found between DHEA-S levels and impairment in selected cognitive domains. Cox regression analysis showed that baseline DHEA-S levels were not associated with cumulative 6-year mortality. CONCLUSIONS: In a sample of newly-diagnosed DAT patients, we did not find significant association between presence of DAT or impairment in cognitive domains and DHEA-S levels; baseline DHEA-S levels are not associated with cumulative mortality in patients and controls.

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. DESIGN: Observational. SETTING: Vascular surgery day hospital. PARTICIPANTS: The analysis included 103 patients (mean age 72.6+/-7.0, 73 men), of whom 50 had LICA disease (29 symptomatic). MEASUREMENTS: Cognitive function was evaluated (age- and education-adjusted Mini-Mental State Examination (MMSE), and Clock tests (CLOX1 and 2)) at baseline and at the end of the study period (average follow-up+/-standard deviation 44.4+/-14.3 months) in a sample of patients aged 65 and older, free from cognitive impairment, consecutively undergoing CE. RESULTS: At the end of the study period, MMSE, CLOX1, and CLOX2 scores were significantly lower in patients with symptomatic LICA disease (P<.001, P<.001, and P=.002, respectively) and not in the other groups of patients. Patients with symptomatic LICA disease had greater risk of cognitive decline than other individuals according to MMSE score (F=5.18, P=.002) or CLOX1 and 2 scores (F=5.66, P=.001, and F=4.33, P=.006, respectively). CONCLUSION: Patients undergoing CE for symptomatic LICA disease appear to be at greater risk of cognitive decline than other subjects. These findings suggest that future studies should evaluate the effects on cognitive function of different timing for CE in patients with LICA and RICA disease.

Cognitive function after carotid endarterectomy: greater risk of decline in symptomatic patients with left internal carotid artery disease.

BACKGROUND: The risk of cognitive decline in patients undergoing carotid endarterectomy (CE) for left internal carotid artery (ICA) (LICA) disease before or after the occurrence of ischemic symptoms has not been fully elucidated. We evaluated whether patients undergoing CE for symptomatic LICA stenosis have greater risk of cognitive decline than patients with asymptomatic LICA disease or right ICA disease. METHODS: In a series of patients aged 65 years and older, consecutively undergoing CE and free from cognitive impairment, cognitive function was evaluated through the age- and education-adjusted Mini Mental State Examination and the Clock Drawing Task at baseline and at the end of the study period (average follow-up: 44.4 +/- 14.3 months). RESULTS: The analysis included 103 patients (mean age 72.6 +/- 7.0 years; 73 men), of whom 50 had LICA disease (29 symptomatic). At the end of the study period, Mini Mental State Examination score was reduced in patients with symptomatic LICA disease (P < .001) but not in other patients, whereas the Clock Drawing Task score was reduced in both patients with LICA and right ICA. Patients with symptomatic LICA disease had greater risk of cognitive decline than other individuals, either measured by the Mini Mental State Examination score (F = 5.18, P = .002) or by the Clock Drawing Task score (F = 9.42, P = .001). CONCLUSIONS: Patients undergoing CE for symptomatic LICA disease appear to be at increased risk of cognitive decline than other individuals. Further studies are needed to confirm these findings and to evaluate whether LICA endarterectomy before occurrence of cerebrovascular ischemic symptoms may provide additive benefit in the prevention of cognitive decline.