Italian guidance on Dementia Day Care Centres: A position paper.

Dementia Day Care Centres (DDCCs) are defined as services providing care and rehabilitation to people with dementia associated with behavioural and psychological symptoms (BPSD) in a semi-residential setting. According to available evidence, DDCCs may decrease BPSD, depressive symptoms and caregiver burden. The present position paper reports a consensus of Italian experts of different disciplines regarding DDCCs and includes recommendations about architectural features, requirements of personnel, psychosocial interventions, management of psychoactive drug treatment, prevention and care of geriatric syndromes, and support to family caregivers. DDCCs architectural features should follow specific criteria and address specific needs of people with dementia, supporting independence, safety, and comfort. Staffing should be adequate in size and competence and should be able to implement psychosocial interventions, especially focused on BPSD. Individualized care plan should include prevention and treatment of geriatric syndromes, a targeted vaccination plan for infectious diseases including COVID-19, and adjustment of psychotropic drug treatment, all in cooperation with the general practitioner. Informal caregivers should be involved in the focus of intervention, with the aim of reducing assistance burden and promoting the adaptation to the ever-changing relationship with the patient.

Predictors and prognosis of delirium among older subjects in cardiac intensive care unit: focus on potentially preventable forms.

BACKGROUND: Delirium is a common and potentially preventable condition in older individuals admitted to acute and intensive care wards, associated with negative prognostic effects. Its clinical relevance is being increasingly recognised also in cardiology settings. The aim of the present study was to assess the prevalence, incidence, predictors and prognostic role of delirium in older individuals admitted to two cardiology intensive care units. METHODS: All patients aged over 65 years consecutively admitted to the two participating cardiology intensive care units were enrolled. Assessment on admission included acute physiological derangement (modified rapid emergency medicine score, REMS), chronic comorbidity, premorbid disability and dementia. The Confusion Assessment Method-Intensive Care Unit was applied daily for delirium detection. RESULTS: Of 497 patients (40% women, mean age 79 years), 18% had delirium over the entire cardiology intensive care unit course, half of whom more than 24 hours after admission (incident delirium). Advanced age, a main diagnosis of ST-segment elevation myocardial infarction or acute respiratory failure, modified REMS, comorbidity and dementia were independent predictors of delirium. Adjusting for patient's features on admission, incident delirium was predicted by invasive procedures (insertion of peripheral arterial catheter, urinary catheter, central venous catheter, naso-gastric tube and intra-aortic balloon pump). In a logistic regression model, delirium was an independent predictor of inhospital mortality (odds ratio 3.18, 95% confidence interval 1.02, 9.93). CONCLUSIONS: Eighteen per cent of older cardiology intensive care unit patients had delirium, with half of the cases being incident, thus potentially preventable. Invasive procedures were independently associated with incident delirium. Delirium was an independent predictor of inhospital mortality. Awareness of delirium should be increased in the cardiology intensive care unit setting and prevention studies are warranted.

Ambulatory blood pressure monitoring in older nursing home residents: diagnostic and prognostic role.

BACKGROUND: Older subjects living in nursing homes (NHs) show a high prevalence of multimorbidity, disability, and cognitive impairment. The clinical meaning of arterial hypertension (AH) in this population is unclear, and few studies have adopted ambulatory blood pressure monitoring (ABPM) with this purpose. The aims of the study were to evaluate the concordance between office and monitored blood pressure in a sample of NH residents and to assess the prognostic meaning of ABPM parameters after 1 year. METHODS: NH residents underwent a comprehensive geriatric assessment and 24-hour ABPM (Spacelabs 90207). White-coat hypertension (WCH) was defined as office blood pressure of 140/90 or higher and ABPM lower than 135/85 mm Hg. Vital status was assessed after 1 year. RESULTS: A total of 100 residents (mean age 83, 51% affected by AH) showed WCH in 33% of cases and in 70% of cases elevated office blood pressure. Correlation between monitored and office blood pressure was limited for systolic (R = 0.30) and nonsignificant for diastolic blood pressure (R = 0.11). Disability and behavioral disorders were independently associated with 1-year mortality. No ABPM parameter, except low nighttime systolic blood pressure variability, was associated with 1-year mortality. CONCLUSIONS: Concordance between office and ABPM values is limited, and WCH prevalence is high among NH residents. Survival at 1-year follow-up is predicted by disability and behavioral disorders, but is not associated with blood pressure values.

Two-year morbidity and mortality in elderly patients with syncope.

BACKGROUND: syncope is a common cause of hospitalisation in the elderly. However, morbidity and mortality in elderly patients with syncope is not well established. METHODS: two-hundred and forty-two patients older than 65 years consecutively referred to the participating centres for evaluation of transient loss of consciousness were enrolled in a multicentre 2-year longitudinal observational study. Mortality and syncope recurrences were recorded and multidimensionally evaluated at 6, 12, 18 and 24 months. FINDINGS: at 24 months, total mortality was 17.2% and syncope recurrence was 32.5%. Cardiac syncope was more frequent in deceased than in survivor patients (21.7 versus 12.3%; P = 0.03), whereas neuro-mediated (62.1 versus 66.2%; P = 0.357) and unexplained syncope (10.8 versus 11.8%; P = 0.397) did not differ between the two groups. Drug-induced and/or multifactorial syncope was less frequent in patients with syncope recurrence (5.7 versus 10.7%; P = 0.02). Kaplan-Meyer curves indicated that mortality and syncope recurrence increased significantly with age (P = 0.006 and P = 0.008, respectively). At multivariate analysis, mortality was significantly predicted by age and comorbidity (hazard ratios: 1.17 and 1.39, and 95% confidence interval 1.01-1.37 and 1.01-1.93, respectively), and syncope recurrence by age and disability (hazard ratio: 1.13 and 1.04, 95% confidence interval 1.01-1.25 and 1.04-2.25, respectively). Depression increased from baseline to the end of follow-up (from 28.3 to 41.4%; P = 0.001). CONCLUSIONS: in our patients, mortality was related to increasing age and comorbidity, whereas recurrence was related to increasing age and disability. Cardiac syncope was more frequent in deceased than in survivor patients, and syncope recurrence was high despite a low incidence of unexplained syncope.

Trandolapril, but not verapamil nor their association, restores the physiological renal hemodynamic response to adrenergic activation in essential hypertension.

The purpose of this study was to evaluate the effects of antihypertensive drugs on renal hemodynamics in hypertensive patients during an adrenergic activation by mental stress (MS), which induces renal vasoconstriction in healthy subjects. Renal hemodynamics was assessed twice in 30 middle-aged essential hypertensive patients (57±6 years)-after 15 days of pharmacological wash-out and after 15 days of treatment with Trandolapril (T, 4 mg, n=10), Verapamil (V, 240 mg, n=10), or both (T 2 mg+V 180 mg, n=10). Each experiment consisted of 4 30-min periods (baseline, MS, recovery I and II). Renal hemodynamics was evaluated with effective renal plasma flow (ERPF) and glomerular filtration rate (GFR) from plasminogen activator inhibitor and inulin clearance, respectively. MS increased blood pressure (BP) to a similar extent before and after each treatment. Before treatment, the increasing BP was not associated with any modification of ERPF in the 3 groups. Renal vascular resistances (RVR) markedly increased during MS (+23% in the T group, +21.6% in the V group, and +32.9% in the T+V group); GFR remained constant during the whole experiment. After treatment, ERPF decreased significantly during MS in the T group (-15%, P<0.05) and in the V group (-11.7%, p<0.01); in the T+V group, ERPF modifications were not statistically significant (P=0.07). In the T group, ERPF reverted to baseline values at the end of the stimulus, whereas in the V group, renal vasoconstriction was more prolonged. Only in hypertensive patients treated with 4 mg of T, RVR reverted to baseline during the recovery I, whereas in the V group, RVR remained elevated for the whole experiment. No modifications of GFR were observed in all groups. The kidney of hypertensive patients cannot react to a sympathetic stimulus with the physiological vasoconstriction. A short-term antihypertensive treatment with 4 mg of T restores the physiological renal response to adrenergic activation.

Coenzyme Q10 terclatrate and creatine in chronic heart failure: a randomized, placebo-controlled, double-blind study.

BACKGROUND: Studies have suggested that micronutrient deficiency has some role in the progression of chronic heart failure (CHF). HYPOTHESIS: Oral supplementation with coenzyme Q(10) (CoQ(10)) and creatine may reduce mitochondrial dysfunction that contributes to impaired physical performance in CHF. METHODS: We conducted a randomized, double-blind, placebo-controlled trial to determine the effect of a mixture of water-soluble CoQ(10) (CoQ(10) terclatrate; Q-ter) and creatine on exercise tolerance and health-related quality of life. Exercise tolerance was measured as total work capacity (kg·m) and peak oxygen consumption (VO(2), mL/min/kg), both from a cardiopulmonary exercise test. Health-related quality of life was measured by the Sickness Impact Profile (SIP) in CHF secondary to left ventricular systolic dysfunction (left ventricular ejection fraction ≤ 35%). After baseline assessment, 67 patients with stable CHF were randomized to receive Q-ter 320 mg + creatine 340 mg (n = 35) or placebo (n = 32) once daily for 8 weeks. RESULTS: At multivariate analysis, 8-week peak VO(2) was significantly higher in the active treatment group than in the placebo group (+1.8 ± 0.9 mL/min/kg, 95% CI: 0.1-3.6, P < 0.05). No untoward effects occurred in either group. CONCLUSIONS: This study suggests that oral Q-ter and creatine, added to conventional drug therapy, exert some beneficial effect on physical performance in stable systolic CHF. Results may support the design of larger studies aimed at assessing the long-term effects of this treatment on functional status and harder outcomes.

Animal-assisted activity and emotional status of patients with Alzheimer's disease in day care.

BACKGROUND: Preliminary studies suggest beneficial effects of animal-assisted activities (AAA) on behavioral and psychological symptoms of dementia (BPSD), but data are inconsistent. This study aimed to assess the effect of AAA with dogs on cognition, BPSD, emotional status and motor activity in severe Alzheimer's disease (AD). METHODS: Ten patients attending an Alzheimer Day Care Center (ADCC) participated in a repeated measures study, which included: two weeks' pre-intervention, three weeks' control activity with plush dogs (CA), and three weeks' AAA. Cognitive function (Severe Impairment Battery), mood (Cornell Scale for Depression in Dementia; CSDD), BPSD (Neuropsychiatric Inventory; NPI) and agitation (Cohen-Mansfield Agitation Inventory; CMAI) were assessed at baseline and after each period. Observed Emotion Rating Scale (OERS) for emotional status, Agitated Behavior Mapping Instrument (ABMI) and a checklist for motor activity were completed across the study periods, both during intervention sessions and after three hours. RESULTS: Cognition and NPI were unchanged across the study. Declines in the CMAI and CSDD scores after AAA were not significant, while the NPI anxiety item score decreased in comparison with CA (CA 3.1±2.3, AAA 1.5±2.7, p = 0.04). OERS "sadness" decreased (p = 0.002), while "pleasure" (p = 0.016) and "general alertness" (p = 0.003) increased during AAA compared with CA sessions, and observed sadness remained lower after three hours (p = 0.002). Motor activity increased significantly during AAA. CONCLUSION: In this sample of severe AD patients in ADCC, AAA was associated with a decrease in anxiety and sadness and an increase in positive emotions and motor activity in comparison with a control activity.

Efficacy of physiotherapy interventions late after stroke: a meta-analysis.

OBJECTIVE: Physiotherapy is usually provided only in the first few months after stroke, while its effectiveness and appropriateness in the chronic phase are uncertain. The authors conducted a systematic review and meta-analysis of randomised clinical trials (RCT) to evaluate the efficacy of physiotherapy interventions on motor and functional outcomes late after stroke. METHODS: The authors searched published studies where participants were randomised to an active physiotherapy intervention, compared with placebo or no intervention, at least 6 months after stroke. The outcome was a change in mobility and activities of daily living (ADL) independence. The quality of the trials was evaluated using the PEDro scale. Findings were summarised across studies as effect size (ES) or, whenever possible, weighted mean difference (WMD) with 95% CI in random effects models. RESULTS: Fifteen RCT were included, enrolling 700 participants with follow-up data. The meta-analysis of primary outcomes from the original studies showed a significant effect of the intervention (ES 0.29, 95% CI 0.14 to 0.45). The efficacy of the intervention was particularly evident when short- and long-distance walking were considered as separate outcomes, with WMD of 0.05 m/s (95% CI 0.008 to 0.088) and 20 m (95% CI 3.6 to 36.0), respectively. Also, ADL improvement was greater, though non-significantly, in the intervention group. No significant heterogeneity was found. INTERPRETATION: A variety of physiotherapy interventions improve functional outcomes, even when applied late after stroke. These findings challenge the concept of a plateau in functional recovery of patients who had experienced stroke and should be valued in planning community rehabilitation services.

Relationship between cognitive function and 6-minute walking test in older outpatients with chronic heart failure.

BACKGROUND AND AIMS: Cognitive decline and heart failure frequently coexist in the elderly. Although an epidemiologic association may partially explain this finding, cerebral hypoperfusion and cardioembolism have been advocated as pathophysiological links. The aim of the present study was to evaluate the relationship between mild cognitive decline and exercise capacity in older outpatients with chronic heart failure (CHF). METHODS: We studied 80 elderly outpatients with stable CHF, mainly of ischemic etiology, assessing total exercise capacity with the 6-minute walking test (6MWT) and global cognitive function with the Mini Mental State Examination (MMSE). CHF severity, emotional status, comorbidity, disability and disease-specific quality of life were also determined at the time of enrollment. RESULTS: A positive association was observed between the distance walked at 6MWT and MMSE score, even after adjusting for demographic parameters, indexes of CHF severity, comorbidities, level of disability, and quality of life. CONCLUSIONS: An easy and reliable measure of cardiovascular global performance is independently associated with cognitive function in older outpatients affected by CHF. In the context of global aging, this observation emphasizes the importance of a comprehensive assessment, encompassing a standard, brief and reliable cognitive evaluation, in elderly CHF outpatients.

Left ventricular remodeling in the elderly with acute anterior myocardial infarction treated with primary coronary intervention.

We compared left ventricular (LV) remodeling following a first time acute anterior ST-elevation myocardial infarction (aSTEMI) treated with primary coronary intervention (pPCI) in different age groups. A total of 116 patients, 61 aged <65 and 55 aged >or=65 years, who survived after a recent aSTEMI treated with pPCI, underwent dobutamine stress-echocardiography (DSE) and non-invasive measurement of left anterior descending coronary artery flow reserve (CFR) during intravenous adenosine infusion. Baseline LV dimensions and systolic function were similar between the two groups; wall motion score indices during all DSE stages and CFR were also similar. In both groups, the LV ejection fraction was positively affected by the presence of viability in the necrosis area and by a higher CFR, but negatively influenced by viability in a remote area, an indirect sign of an extensive infarction size. This study demonstrates that PCI in the geriatric population with aSTEMI is as equally effective as in younger subjects, in terms of LV remodeling and function.

Atrial fibrillation is a possible marker of frailty in hospitalized patients: results of the GIFA Study.

BACKGROUND AND AIMS: Atrial fibrillation (AF) is the most common arrhythmia in elderly people, who are particularly exposed to its most severe complications, such as stroke, worsening heart failure and dementia. Some studies demonstrate that AF is associated with increased mortality in home-dwelling subjects, but little is known about the clinical impact of the arrhythmia in hospitalized patients. We studied the clinical associations and effects of AF on the 23,174 hospitalized patients enrolled in the GIFA (Gruppo Italiano di Farmacoepidemiologia nell'Anziano) Study. METHODS: Patients were divided into three groups according to the absence or presence of AF (sinus rhythm, non_AF; AF as main diagnosis, AF_main; AF as comorbid condition, AF_associated) and stratified into four age-groups (< or =60, 61-70, 71-80 and >80 yrs). RESULTS: AF_associated patients were older, more frequently disabled, and characterized by greater comorbidity and longer in-hospital length of stay. Urea nitrogen concentration was higher, and total cholesterol was lower in AF_associated patients, compared with the other two groups. Overall mortality was 6.0%. Mortality was higher in AF_associated patients (non_AF: 6.0% vs AF_associated: 7.1% vs AF_main: 0%, p<0.001). CONCLUSIONS: Our results suggest that, in hospitalized patients, AF as a comorbid condition is associated with worse metabolic profile and clinical outcomes, and thus, may represent a marker of frailty.

Low diastolic ambulatory blood pressure is associated with greater all-cause mortality in older patients with hypertension.

OBJECTIVES: To assess the relationship between office and ambulatory systolic blood pressure (SBP), diastolic blood pressure (DBP), and pulse pressure (PP) and total mortality in elderly patients with hypertension. DESIGN: Observational prospective cohort study. SETTING: Hypertension outpatient clinic in a geriatric academic hospital. PATIENTS AND METHODS: Eight hundred five older (> or =60) subjects with hypertension underwent office and ambulatory BP measurement. Mortality was assessed after a mean follow-up of 3.8 years. RESULTS: In a total of 3,090 person-years of follow-up, 107 participants died (average mortality rate 3.5% per year). With bivariate analysis, participants who died had higher SBP and PP and lower DBP, with office and ambulatory measurements. Mortality rates were greater with higher SBP and lower with higher DBP. As a combined effect of these trends, PP was associated with the widest death rate gradients, from 12 to 66, 13 to 63, and 9 to 70 per 1,000 person-years across office, 24-hour, daytime, and nighttime PP quartiles, respectively. Multivariate Cox analysis confirmed these trends; the adjusted hazard of death increased linearly with increasing ambulatory SBP and PP, whereas it decreased significantly with increasing ambulatory DBP. A five times greater risk of death was detected when comparing night-time PP quartile 4 (median PP value 78 mmHg) with quartile 1 (median PP value 46 mmHg). CONCLUSION: In older patients with hypertension, low DBP and high PP, particularly when measured using ambulatory BP monitoring, are associated with greater risk of death. The achievement of an SBP treatment goal should not be obtained at the expense of an excessive DBP reduction.

Role of beta-blockers in patients admitted for worsening heart failure in a real world setting: data from the Italian Survey on Acute Heart Failure.

AIMS: Randomized trials have shown that beta-blockers (BBs) reduce mortality in chronic heart failure (HF). Less data are available on the role of BBs in patients with acute HF, specifically if BBs should be continued or temporarily withdrawn. The aim of this study was to evaluate the role of BBs on in-hospital outcomes of patients admitted for worsening HF in a Cardiology setting. METHODS AND RESULTS: One thousand five hundred and seventy-two patients enrolled in the Italian Survey on Acute HF were evaluated. According to the BB therapy before and during hospitalization, four groups were defined: group A, no/no (51.6%); group B, no/yes (16.4%); group C, yes/no (9.0%); and group D, yes/yes (23.0%). Groups B and D had a significantly lower in-hospital mortality rate (group B 1.2%, group D 2.8%, group A 10.1%, and group C 12.1%; P < 0.0001). The association between non-use or withdrawal of BBs and higher mortality rate was confirmed by the multivariable analysis [group D, reference group; odds ratio (OR) 3.28, 95% confidence interval (CI) 1.47-7.32 and OR 4.20, 95% CI 1.59-11.10 for groups A and C, respectively], whereas no difference was found between groups B and D (OR 0.34, 95% CI 0.07-1.78). CONCLUSION: In patients hospitalized for worsening HF, non-use or discontinuation of BBs was associated with a significant higher mortality.

Role of early symptoms in assessment of syncope in elderly people: results from the Italian group for the study of syncope in the elderly.

OBJECTIVES: To assess the ability of specific early symptoms to predict cardiac and noncardiac syncope in elderly people. DESIGN: Multicenter cross-sectional observational study. SETTING: Inpatient geriatric acute care departments and outpatient clinics. PARTICIPANTS: Two hundred forty-two patients with syncope (mean age 79+/-8) consecutively referred for evaluation of transient loss of consciousness to any of six clinical centers participating in the Italian Group for the Study of Syncope in the Elderly (GIS Study). MEASUREMENTS: All patients were assessed according to European Society of Cardiology Syncope guidelines and interviewed about symptoms and signs present before syncope. RESULTS: One hundred seventy-four of 242 patients (75.4%) had noncardiac syncope, and 34 (14.7%) had cardiac syncope; 165 patients (71.1%) related symptoms before the loss of consciousness. When elderly patients with syncope were stratified for the presence and absence of symptoms, noncardiac syncope showed the highest prevalence of symptoms (75.3%, P<.01). Awareness of being about to faint, sweating, blurred vision, and nausea are more prevalent in noncardiac syncope. Dyspnea is more prevalent in cardiac syncope. All symptoms except awareness of being about to faint and weakness had good specificity, but sensitivity was low for all symptoms considered. Multivariate regression analysis adjusted for sex and age indicated that nausea (relative risk (RR)=3.7, 95% confidence interval (CI)=1.26-11.2), blurred vision (RR=3.5, 95% CI=1.34-9.59), and sweating (RR=2.8, 95% CI=.21-6.89) were predictive of noncardiac syncope. Dyspnea (RR=5.5, 95% CI=1.0-30.2) was the only symptom predictive of cardiac syncope. CONCLUSION: The data show that symptoms such as nausea, blurred vision, and sweating are predictive of noncardiac syncope, whereas only dyspnea is predictive of cardiac syncope in elderly people.

Prognostic value of exercise stress test and dobutamine stress echo in patients with known coronary artery disease.

BACKGROUND: The aim of this study was to compare the feasibility of dobutamine stress echocardiography (DSE) and exercise stress test (EST) between patients in different age groups and to evaluate their proportional prognostic value in a population with established coronary artery disease (CAD). METHODS: The study sample included 323 subjects, subdivided in group 1 (G1), comprising 246 patients aged <75 years, and group 2 (G2), with 77 subjects aged >or=75 years. DSE and EST were performed before enrollment in a cardiac rehabilitation program; for prognostic assessment, end points were all-cause mortality and hard cardiac events (cardiac death or nonfatal myocardial infarction). RESULTS: During DSE, G2 patients showed worse wall motion score index (WMSI), but the test was stopped for complications in a comparable proportion of cases (54 G1 and 19 G2 patients, P = NS). EST was inconclusive in similarly high proportion of patients in both groups (76% in G1 vs. 84% in G2, P = NS); G2 patients reached a significantly lower total workload (6 +/- 1.6 METs in G1 vs. 5 +/- 1.2 METs in G2, P < 0.001). At multivariate analysis, a lower peak exercise capacity (HR 0.566, CI 0.351-0.914, P = 0.020) was associated with higher mortality, while a high-dose WMSI >2 (HR 5.123, CI 1.559-16.833, P = 0.007), viability (HR 3.354, CI 1.162-9.678, P = 0.025), and nonprescription of beta-blockers (HR 0.328, CI 0.114-0.945, P = 0.039) predicted hard cardiac events. CONCLUSION: In patients with known CAD, EST and DSE maintain a significant prognostic role in terms of peak exercise capacity for EST and of presence of viability and an extensive wall motion abnormalities at peak DSE.

Multidisciplinary approach to "accidental" falls in the elderly: a case report.

Falls in the elderly are commonly and often wrongly identified as "accidental". We report a case of an elderly woman admitted to first aid for a trauma due to an accidental fall. Geriatric multidisciplinary evaluation revealed mild cognitive impairment associated with depressive symptoms; both findings made the anamnesis uncertain. Syncope algorithm was applied and "tachy-brady form of sick sinus syndrome" was diagnosed. Differential diagnosis between "accidental" and "apparently accidental" falls in elderly patients is very difficult but a multidisciplinary geriatric evaluation can clarify the correct diagnosis.

Metabolic syndrome and cardiovascular mortality in older type 2 diabetic patients: a longitudinal study.

BACKGROUND: Although age does not seem to modify the association of the metabolic syndrome (MS) with cardiovascular risk in middle-aged individuals, no comparison of risks associated with MS between old and middle-aged persons has been reported so far. METHODS: An observational study was performed on a consecutive series of 1716 type 2 diabetic outpatients (age range: 28-96 years). The diagnosis of MS was made following either the National Cholesterol Education Program-Adult Treatment Panel (NCEP-ATPIII) or the International Diabetes Federation (IDF) criteria. RESULTS: The difference in cardiovascular mortality between patients with and without MS was significant up to the age of 70 years. After adjusting for age and sex, hazard ratios of MS for cardiovascular mortality were 3.03 (95% confidence interval, 1.45-6.29), 1.56 (0.91-2.68), and 1.17 (0.42-3.22) in patients < or =70, 71-80, and >80 years old, respectively. CONCLUSIONS: MS is associated with increased cardiovascular risk in middle-aged type 2 diabetic patients, and the clinical utility of this category in older diabetic individuals is questionable.

Central but not brachial blood pressure predicts cardiovascular events in an unselected geriatric population: the ICARe Dicomano Study.

OBJECTIVES: The present study investigated whether central blood pressure (BP) predicts cardiovascular (CV) events better than brachial BP in a cohort of normotensive and untreated hypertensive elderly individuals. BACKGROUND: Limited and conflicting data have been reported on the prognostic relevance of central BP compared with brachial BP. METHODS: Community-dwelling individuals > or =65 years of age, living in Dicomano, Italy, underwent an extensive clinical assessment in 1995 including echocardiography and carotid ultrasonography and applanation tonometry. In 2003, vital status and CV events were assessed, reviewing the electronic database of the Regional Ministry of Health. Only normotensive (n = 173) and untreated hypertensive subjects (95 diastolic and 130 isolated systolic) were included in the present analysis. RESULTS: During 8 years, 106 deaths, 45 of which were cardiovascular, and 122 CV events occurred. In univariate analyses, both central and brachial systolic blood pressure (SBP) and pulse pressure (PP) predicted CV events (all p < 0.005); however, in multivariate analyses, adjusting for age and gender, higher carotid SBP and PP (hazard ratios 1.19/10 and 1.23/10 mm Hg, respectively; both p < 0.0001) but neither brachial SBP nor PP independently predicted CV events. Similarly, higher carotid SBP but not brachial pressures independently predicted CV mortality (hazard ratio 1.37/10 mm Hg; p < 0.0001). CONCLUSIONS: Our prospective study in an unselected geriatric population demonstrates superior prognostic utility of central compared with brachial BP.

Subtle neurological abnormalities as risk factors for cognitive and functional decline, cerebrovascular events, and mortality in older community-dwelling adults.

BACKGROUND: Subtle, but clinically detectable, neurological abnormalities (SNAs) are associated with impaired physical performance in elderly persons without overt neurological diseases. We investigated whether SNAs were prospectively associated with cognitive and functional status, death, and cerebrovascular events (CVEs) in older community-dwelling individuals. METHODS: In participants without history of stroke, parkinsonism and dementia, or cognitive impairment, a score (N(SNA)) was obtained by summing SNAs detected with a simple neurological examination. Cognitive status and disability were reassessed 4 years later, and deaths and CVEs were documented over 8 years. RESULTS: Of 506 participants free of neurological diseases (mean [SEM] age, 71.9 [0.3] years; 42% were men), 59% had an N(SNA) of 1 or more (mean [SEM], 1.1 [0.06]; range, 0-8). At baseline, the N(SNA) increased with age and with declining cognitive and physical performance, depressive symptoms, and disability, after adjusting for several covariates, but did not increase with falls and urinary incontinence. The N(SNA) prospectively predicted worsening cognitive status and disability, adjusting for demographics and for baseline comorbidity and cognitive and physical performance. The mortality rates were 22.6, 23.3, 23.9, 58.6, and 91.9 per 1000 person-years in participants with an N(SNA) of 0, 1, 2, 3, and 4 or higher, respectively. Compared with an N(SNA) of less than 3, having an N(SNA) of 3 or higher was associated with an increased adjusted risk of death (hazard ratio, 1.77; 95% confidence interval [CI], 1.25-2.74) and of CVE (hazard ratio, 1.94; 95% CI, 1.07-3.54) over 8 years. CONCLUSION: In this sample of older community-dwelling persons without overt neurological diseases, multiple SNAs were associated with cognitive and functional decline and independently predicted mortality and CVEs.

Day Care for older dementia patients: favorable effects on behavioral and psychological symptoms and caregiver stress.

OBJECTIVE: To assess the effects of Day Care (DC) on older subjects with dementia and their caregivers. METHODS: Thirty patients with dementia, consecutively admitted to a DC, were compared with 30 patients, matched for age and cognitive function, who received usual home care (HC). Primary caregivers were compared as well. At baseline and after 2 months, patients were assessed for cognitive and functional status, behavioral and psychological symptoms [Neuropsychiatric Inventory (NPI)] and psychotropic drugs use, and caregivers were evaluated for care burden [Caregiver Burden Inventory (CBI)] and depressive symptoms. RESULTS: After adjusting for potential confounders, NPI score significantly decreased in DC group, with a reduction of psychotropic drugs prescription, whereas it increased in HC. No significant between-group difference was observed for cognitive and functional change. CBI significantly decreased in DC, but not HC, caregivers, with no significant between-group difference in depressive symptoms change. CONCLUSIONS: A 2-month period of DC assistance is effective in reducing behavioral and psychological symptoms of dementia patients and in alleviating caregivers' burden.