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.

Truly unexplained falls after evaluation for syncope: A new diagnostic entity with severe prognosis.

OBJECTIVE: To compare one-year mortality risk associated with syncope and unexplained fall in older adults with dementia. METHODS: 522 patients (aged >65 years) with dementia and history of transient loss of consciousness and/or unexplained falls were evaluated. The diagnosis of syncope was based on European Society of Cardiology guidelines. A "Syncopal Fall" was defined in patients with an initial clinical presentation of unexplained fall, but a final diagnosis of syncope after complete assessment. A "Truly Unexplained Fall" was defined in patients with an initial clinical presentation of unexplained fall, in whom a diagnosis of syncope had been excluded after the diagnostic work-up. One-year follow-up was assessed by phone interview. RESULTS: Follow-up data were available for 501 participants (mean age 83 ± 6 years, 65% female). After a mean follow-up of 324 ± 93 days, death from any cause was reported in 188 participants (24%). Advanced age, male sex, cognitive and functional impairment were associated with a higher mortality rate. Patients with "Truly Unexplained Falls" had a higher mortality risk compared with syncope and "Syncopal Fall". A diagnosis of "Truly Unexplained Falls" remained an independent predictor of one-year all-cause mortality in multivariate model. CONCLUSIONS: We propose the novel diagnostic category of "Truly Unexplained Fall", resulting from the application of syncope guidelines to subjects with unexplained falls. This condition in older adults with dementia is a predictor of one-year all-cause mortality. For this new high risk profile, we advice a comprehensive geriatric assessment focused on risk factors for fall, aimed at a possible improvement of prognosis.

Atrial Fibrillation in Older Patients with Syncope and Dementia: Insights from the Syncope and Dementia Registry.

OBJECTIVES: To evaluate the clinical characteristics and the long-term outcome of atrial fibrillation (AF) patients with dementia and history of syncope or falls. DESIGN: Observational: analysis of a prospective registry. SETTING AND PARTICIPANTS: Between 2012 and 2016, the Syncope and Dementia Registry enrolled patients in 12 geriatric departments. Follow-up evaluation was at 12 months. MEASURES: Clinical, functional, and cognitive assessment. RESULTS: Of the 522 patients (women, 62.1%; Mini-Mental State Examination 17 ± 6), 26.4% have or presented an AF history. Patients with AF were older (85 ± 6 vs 83 ± 6 years, P = .012), with higher heart rate (78 ± 17 vs. 73 ± 14 bpm, P < .001), prescribed drugs (6.9 ± 2.9 vs 5.9 ± 2.7, P < .001), and an increased number (3.9 ± 2.0 vs 3.0 ± 1.8, P < .001) and severity of comorbidities. Oral anticoagulant therapy was underprescribed (39.9%). Cardiac syncope was more frequently diagnosed (18.8 vs 4.9%, P < .001). At multivariate analysis, AF patients were characterized by advanced age, a higher severity of comorbidities, a greater number of prescribed drugs, an increased heart rate, and a more frequent presence of cardiac symptoms. One-year mortality differed little between patients with and without AF (27.7 vs 22.1%, P = .229). In the arrhythmia group, multivariate predictors of prognosis were disability (number of lost BADLs; P = .020) and a higher heart rate (P = .006). CONCLUSIONS AND IMPLICATIONS: AF and postural stability-related issues often co-exist in persons with dementia. This complex of conditions is associated with an intricate clinical picture, underprescription of oral anticoagulants, and high long-term mortality. Future studies are needed to evaluate the effects of therapy optimization in this population.

Prevalence, predictors and clinical implications of prolonged corrected QT in elderly patients with dementia and suspected syncope.

BACKGROUND: Long QT and use of QT-prolonging drugs are common among older patients receiving polytherapies, but real-world evidence on their impact in clinical practice is controversial. We investigated prevalence, variables associated and clinical implications of prolonged corrected QT (QTc) among patients from the Syncope and Dementia study. METHODS: Observational, prospective, multicenter study. Patients≥65 years with dementia and fall suspected for syncope in the previous three months were enrolled. Several clinical variables and the complete list of medications were recorded for each patient. A 12­lead ECG was obtained and corrected QT was calculated by the Bazett's formula. One-year followup for death and recurrent syncope was performed. RESULTS: Prolonged QTc was observed in 25% of the 432 enrolled patients (mean age 83.3), and was significantly associated with male gender (OR 2.09; 95% CI 1.34-3.26) and diuretics use (OR 1.85; 95% CI 1.18-2.90). At one-year 23.3% of patients died and 30.4% reported at least one recurrent event. Variables associated with one-year mortality were: age, male gender, atrial fibrillation (AF), use of calcium channel blockers and prolonged QTc (OR 1.80; 95% CI 1.01-3.20). Among patients with prolonged QTc a significant interaction for mortality was found with AF. Recurrent events were associated with the use of antiplatelets, cholinesterase. inhibitors and antipsychotics, but not with prolonged QTc. CONCLUSIONS: We documented a high prevalence of prolonged QTc, that was associated with male gender and diuretics but not with psychoactive medications. Patients with prolonged QTc had higher one-year mortality, that was four-fold increased in those with concomitant AF.

Effects of low blood pressure in cognitively impaired elderly patients treated with antihypertensive drugs.

IMPORTANCE: The prognostic role of high blood pressure and the aggressiveness of blood pressure lowering in dementia are not well characterized. OBJECTIVE: To assess whether office blood pressure, ambulatory blood pressure monitoring, or the use of antihypertensive drugs (AHDs) predict the progression of cognitive decline in patients with overt dementia and mild cognitive impairment (MCI). DESIGN, SETTING, AND PARTICIPANTS: Cohort study between June 1, 2009, and December 31, 2012, with a median 9-month follow-up of patients with dementia and MCI in 2 outpatient memory clinics. MAIN OUTCOMES AND MEASURES: Cognitive decline, defined as a Mini-Mental State Examination (MMSE) score change between baseline and follow-up. RESULTS: We analyzed 172 patients, with a mean (SD) age of 79 (5) years and a mean (SD) MMSE score of 22.1 (4.4). Among them, 68.0% had dementia, 32.0% had MCI, and 69.8% were being treated with AHDs. Patients in the lowest tertile of daytime systolic blood pressure (SBP) (≤ 128 mm Hg) showed a greater MMSE score change (mean [SD], -2.8 [3.8]) compared with patients in the intermediate tertile (129-144 mm Hg) (mean [SD], -0.7 [2.5]; P = .002) and patients in the highest tertile (≥ 145 mm Hg) (mean [SD], -0.7 [3.7]; P = .003). The association was significant in the dementia and MCI subgroups only among patients treated with AHDs. In a multivariable model that included age, baseline MMSE score, and vascular comorbidity score, the interaction term between low daytime SBP tertile and AHD treatment was independently associated with a greater cognitive decline in both subgroups. The association between office SBP and MMSE score change was weaker. Other ambulatory blood pressure monitoring variables were not associated with MMSE score change. CONCLUSIONS AND RELEVANCE: Low daytime SBP was independently associated with a greater progression of cognitive decline in older patients with dementia and MCI among those treated with AHDs. Excessive SBP lowering may be harmful for older patients with cognitive impairment. Ambulatory blood pressure monitoring can be useful to help avoid high blood pressure overtreatment in this population.

Tolerability of ambulatory blood pressure monitoring (ABPM) in cognitively impaired elderly.

OBJECTIVE: Recent guidelines have widened clinical indications for out-of-office blood pressure measurement, including home blood pressure monitoring and ambulatory blood pressure monitoring (ABPM), suggesting the latter as recommended method in cognitively impaired patients. There is, however, a widespread belief that ABPM could be poorly tolerated in dementia, often leading to withdraw from its use in these patients. AIM: To assess the actual tolerability of ABPM in a group of cognitively impaired elderly, affected by dementia or mild cognitive impairment (MCI). METHODS: We evaluated 176 patients aged 65 + years, recruited in two different memory clinics, with a Mini Mental State Examination (MMSE) between 10 and 27. Behavioral and psychological symptoms were assessed with Neuropsychiatric Inventory (NPI). A patient was considered tolerant if able to keep the device on continuously for 24 h. The minimum number of correct measurements required was 70% of the predicted total number. RESULTS: 16% of patients wore the device for less than 24 h. Dividing the study population in tertiles of MMSE performance, 29% failed to tolerate the device in the lowest, 12% in the middle and 7% in the highest tertile (p < 0.01). Dividing the study population in tertiles of NPI performance, 30% of patients failed in the highest, 19% in the middle and 8% in the lowest tertile (p = 0.02); 31% of patients who tolerated the device did not achieve the minimum number of measurements required, with a mean number of 63% of predicted measurements. CONCLUSION: The ABPM proved a generally well-tolerated technique even in cognitively impaired elderly. Only a minority of subjects with poorer cognitive performances and greater behavioral symptoms did not tolerate the monitoring. Among most patients who failed to achieve the minimum number of measurements needed, the number of valid measurements was very close to the minimum required.

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.

Cardiovascular remodeling is greater in isolated systolic hypertension than in diastolic hypertension in older adults: the Insufficienza Cardiaca negli Anziani Residenti (ICARE) a Dicomano Study.

OBJECTIVE: We investigated cardiac and vascular remodeling in an unselected older population with either diastolic hypertension (HTN) or isolated systolic hypertension (ISH). BACKGROUND: Isolated systolic hypertension accounts for a substantial proportion of hypertension in individuals older than 65 years and is strongly associated with an increased risk of cardiac and cerebrovascular events. The exact mechanisms underlying the increased risk associated with ISH and elevated pulse pressure (PP), in comparison with HTN, have not been extensively investigated. METHODS: Community-dwelling residents age >/=65 years in a small town in Italy (Dicomano) were enrolled. Untreated subjects considered in this study included 173 normotensive subjects (blood pressure [BP] <140/90 mm Hg), 95 subjects with HTN (diastolic BP >/=90 mm Hg), and 43 subjects with ISH (BP >/=160/<90 mm Hg). All subjects underwent extensive clinical examination, echocardiography, carotid ultrasonography, and carotid applanation tonometry. RESULTS: Subjects with ISH had higher left ventricular (LV) mass, which was independently related to PP but not to systolic or mean pressures. Both carotid wall cross-sectional area and vascular stiffness were greater in ISH patients than in HTN and normal subjects and were independently related to PP but not to systolic BP. In addition, ISH was associated with a higher prevalence of carotid plaque and more extensive carotid atherosclerosis. CONCLUSIONS: In our community-based elderly population, individuals with ISH had higher prevalences of LV hypertrophy and carotid atherosclerosis than subjects with HTN despite lower mean BP. These findings provide potential pathophysiologic mechanisms underlying the associations of ISH and PP with increased risk of cardiovascular morbidity and mortality.