Are there any news about the antipsychotic medications in the elderly?

Antipsychotic drugs are widely used in people with dementia to treat neuropsychiatic symptoms such as aggression, agitation and psychosis. Using antipsychotic agents in older patients is difficult, because it depends on co-morbid conditions, side effects, dosing strategies, duration of treatments and combinations of various medications. This paper discusses the use of atypical antipsychotics in a 1-year-observation on a group of patients followed by an expert dementia center.

The chronically ill elderly patients discharged from the hospital: interim report from a controlled study of home care attendance.

This controlled study evaluated various outcomes in a group of 127 chronically ill and frail elderly patients when discharged from a hospital ward, and cared at home, enrolled during 12 months starting from September 2001. The observation of patients is programmed to be of two years from enrollment, with a scheduled program of follow up at baseline,6, 12, and 24 months. Patients (of both sexes) were randomly assigned to one of two groups: (i) Control group (61 patients: mean age 85.2 years) having a usual home care program of assistance, guaranteed by the Social Health Care Service. (ii) Intervention group (66 patients: mean age 83.2 years), for whom the program of care mentioned above was integrated providing collaboration of a home care attendant. This was a lay-working person who has attended a specializing course about care of the elderly and of the very frail. The home attendance was provided for 4-10 hrs daily, according to a program established by a Geriatric Evaluation Unit. The team evaluated the patients at their home,deciding the amount of hours of attendance in the presence of the caregiver. The financial cost of the additional home care attendance was sponsored, totally or in part, according to the financial situation of the patient's family, by the "Fondazione del Monte di Bologna e di Ravenna". This report takes into consideration only few preliminary data, coming from the first 6 months of observation of all the patients included. The two groups were homogeneous when compared statistically at baseline. Data coming form laboratory and biological analysis will be available only at the end of the project as they are recorded in a blind methodology. A lower degree of mortality and of dropouts in the intervention group was observed,compared to the control group, already at 6 months. These outcomes can be considered favorable, and perhaps can be related to the various benefits gained by additional program of home attendance.

Immediate effectiveness of the "new identity" reality orientation therapy (ROT) for people with dementia in a geriatric day hospital.

Techniques of reality orientation in dementia are widely used around the world and indifferent settings. Nevertheless, after the controversies for adverse effects and frustration,by the new millennium "a new era" is coming on where cognitive rehabilitation "has come of age" and a series of positive results appeared until the fulfillment in the global and person-centered approach. This renewed technique may no more be based only on cognitive psychology but it is necessary to apply a more complete psychosocial approach taking into account also emotional, behavioral and functional domains of the globally considered person. The aims of our study are: (1) To assess the global efficacy on cognitive and affective functions. (2) To detect cognitive subsystems more sensible to our three-phase stimulation program. We studied 34 outpatients, 13 men and 21 women, age range 67-88 years, referred to our Expertise Center, all but one affected by mild cognitive impairment(MCI), suffering from mild dementia (clinical dementia rating, CDR <1). After 20 sessions of formal and complementary activities, a comprehensive improvement of cognition, language,memory and affective functions was observed. Semantic fluency improved with high statistically significant difference. The immediate recall, free or cued, appeared more sensible to stimulation than the delayed one. A correlation between a mini mental state examination (MMSE) low basal score and higher performance after the program was also obtained.

WHO and ATPIII proposals for the definition of the metabolic syndrome in patients with Type 2 diabetes.

AIMS: Different criteria have been proposed by the World Health Organization (WHO) and by the Third Report of the National Cholesterol Education Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (ATPIII) for the diagnosis of the metabolic syndrome. Its identification is of particular importance for coronary risk assessment. METHODS: The prevalence of the metabolic syndrome was determined according to the two different proposals in 1569 consecutive subjects with Type 2 diabetes. RESULTS: By the WHO proposal, 81% of cases (95% confidence interval, 79-83) were labelled as metabolic syndrome. Microalbuminuria had the highest specificity (99%) and visceral obesity the highest sensitivity (93%). Seventy-eight per cent of patients (95% CI, 76-80) fulfilled the ATPIII criteria for metabolic syndrome, low HDL-cholesterol having the highest specificity (95%), elevated blood pressure having the highest sensitivity. According to both proposals, 1113 patients were positive; 183 were concordantly negative, indicative of a fairly good agreement (k statistics, 0.464). Subjects only positive for the WHO proposal were more frequently males, had a lower BMI and a higher arterial pressure. Only subjects identified by the ATPIII proposal had a significantly higher prevalence of previously detected coronary heart disease. CONCLUSIONS: Minimum criteria for the metabolic syndrome are met in most patients with Type 2 diabetes. Correct identification of the syndrome is important for an integrated approach to reduce the high costs and the associated disabilities. The ATPIII proposal more clearly identifies the burden of coronary heart disease associated with the metabolic syndrome.

Alpha-1-antichymotrypsin and oxidative stress in the peripheral blood from patients with probable Alzheimer disease: a short-term longitudinal study.

To evaluate the stability and reproducibility of selected peripheral oxidative stress markers and their possible relation to cognitive performance, three different blood samples were taken at 7- to 10-day intervals from 11 patients with probable Alzheimer disease (AD) and 11 nondemented controls. Blood samples were also collected once from 6 patients with vascular dementia (VD). Alpha-1-antichymotrypsin (ACT), C-reactive protein (CRP), glutathione peroxidase (GSH-Px), superoxide dismutase (SOD), lactoferrin (LTF), and total lipid peroxidation (LPO) were then measured. Blood levels of ACT and GSH-Px were increased in AD patients but not in patients with VD. Levels of LTF, CRP, and LPO were comparable between AD patients and controls. Erythrocyte SOD activity was increased in AD patients. Blood levels of ACT negatively correlated with LPO levels and positively correlated with scores of the Global Deterioration Scale of AD patients. ACT might be implicated in controlling oxidative damage of blood lipids and their turnover during the progression of AD.

Clinical assessment of mental decline in elderly people: a proposal for a new quantitative index.

Despite the many instruments available for assessing elderly people, there is a need for additional methods to measure mental decline that would also be applicable in cross sectional and longitudinal studies. With this purpose in mind, our group developed and checked a new instrument, the Index of Mental Decline (IMD), which consists of five clusters of items intended for the assessment of cognition, personal interrelationships, affective disorders, apathy and somatic complaints. To improve its consistency, all clusters and items were evaluated individually, according to their clinical impact. Three levels of symptom importance were determined: absent to very mild, mild to moderate, severe to very severe. Inter-rater reliability and test-retest reliability were demonstrated in a sample of 59 subjects, and proved to be satisfactory. The validity of the IMD was tested in a group of 203 patients, in whom a clinical diagnosis of probable dementia (DSM III-R criteria) had been formulated. The results suggest the effectiveness of the IMD both in quantifying mental decline and monitoring clinical symptoms. The IMD cannot be the first step of diagnostic procedure, but it can be useful for evaluating mental decline in elderly subjects with cognitive disorders. In longitudinal studies, the presence of the same caregiver or informant is compulsory.

Increased chemiluminescence response of neutrophils from the peripheral blood of patients with senile dementia of the Alzheimer's type.

The metabolic activity of circulating neutrophils from patients with senile dementia of the Alzheimer's type (SDAT) was investigated by a chemiluminescence assay and compared with that of old and young healthy controls. Neutrophils from demented patients showed a higher and faster chemiluminescence emission than those of controls when activated in vitro by autologous or heterologous sera. Granulocytes from patients with Parkinson's disease did not show an increased chemiluminescence activity. Moreover, serum from patients with SDAT depressed the chemiluminescence emission of granulocytes from young donors. Serum levels of alpha 1-antichymotrypsin (alpha 1-ACT) were also determined and were found to be higher in demented subjects than in old and young controls. These data suggest that peripheral and systemic indexes of inflammation are present in the disease and might be associated with mental deterioration.

Cerebrospinal fluid of patients with senile dementia of Alzheimer's type shows an increased inhibition of alpha-chymotrypsin.

The inhibition of alpha-chymotrypsin induced by cerebrospinal fluid from patients with senile dementia of Alzheimer's type, vascular dementia, and nondemented controls was investigated. We optimized the sensitivity of the assay so that the inhibition of alpha-chymotrypsin could be measured in all samples. The competitive inhibition was proportional to the amount of cerebrospinal fluid (CSF) added to the reaction mixture. After correction for protein concentration, the inhibition was higher with CSF from patients with senile dementia of Alzheimer's type than with those from patients with vascular dementia or controls. Inhibitory activity appeared to be specific for alpha-chymotrypsin because no inhibition for papain was found. Moreover, the depletion of alpha 1-antichymotrypsin from CSF by immunoadsorption revealed that this serpin was responsible for the disappearance of the inhibitory activity. Our findings suggested that the increased alpha-chymotrypsin inhibitory activity might represent an in vivo functional index of an abnormal protease metabolism in patients with Alzheimer's disease.

Zinc and thymic hormone-dependent immunity in normal ageing and in patients with senile dementia of the Alzheimer type.

Plasma zinc levels were measured in young controls, aged controls, patients with dementia of the Alzheimer type and patients with non-Alzheimer type dementia. Zinc levels decreased with age; however, no difference was found between patients with dementia and age-matched controls. Plasma levels of active or inactive thymulin, a nonapeptide produced and released by the thymus gland, were also determined in young controls, aged controls, patients with dementia of the Alzheimer type and patients with non-Alzheimer type dementia. Basal levels of active thymulin were decreased in aged controls and in patients with dementia. In vitro reactivation of thymulin after zinc addition to plasma samples was decreased in aged controls. A further impairment of thymulin reactivation was present in patients with dementia. A significant age-dependent decrease in lymphocyte proliferation after mitogen stimulation was found; however, no difference was present between aged controls and patients with dementia of the Alzheimer type. Interleukin-2-induced cell activation and its effect on mitogen-induced proliferation were also measured; once again only an age-associated decrease was found. The endocrine function of the thymus of patients with dementia appears to be more compromised than that from aged controls.

[What is in the future for geriatrics? I]. / Quale futuro per la geriatria? Prima parte.

The authors, after an evaluation of the historical course of the geriatrics in England and its contents, point out the importance of this specialty from a demografic, economical, social, epidemiological and cultural point of view.

[What is in the future for geriatrics? II]. / Quale futuro per la geriatria? Seconda parte.

The authors point out the importance of geriatric medicine in the hospital in its traditional goals and in some new proposals: geriatric case finding, general practitioner's education, teaching in nursing schools, family education, pre-retirement courses etc.