Italian Association of Hospital Cardiologists Position Paper 'Gender discrepancy: time to implement gender-based clinical management'.

It has been well assessed that women have been widely under-represented in cardiovascular clinical trials. Moreover, a significant discrepancy in pharmacological and interventional strategies has been reported. Therefore, poor outcomes and more significant mortality have been shown in many diseases. Pharmacokinetic and pharmacodynamic differences in drug metabolism have also been described so that effectiveness could be different according to sex. However, awareness about the gender gap remains too scarce. Consequently, gender-specific guidelines are lacking, and the need for a sex-specific approach has become more evident in the last few years. This paper aims to evaluate different therapeutic approaches to managing the most common women's diseases.

Association of serum uric acid with functional disability in older subjects: a population-based study.

BACKGROUND: The role of serum uric acid (SUA) in the development of adverse health outcomes in advanced age is still uncertain. AIMS: The aim of the study was to assess the association of disability with SUA levels in older community-dwelling subjects. METHODS: We assessed the association of disability with SUA in all 351 inhabitants of Tuscania (Italy) aged 75+. Functional ability was estimated using the instrumental activities of daily living (IADLs). RESULTS: In logistic regression, increasing SUA levels were associated with disability (OR = 1.22; 95%CI = 1.01-1.48; P = .036), after adjusting. The association was independent of both gender and age (P for interaction > 0.050). SUA levels above 5.5 mg/dL best predicted disability. CONCLUSIONS: In older subjects, SUA levels are associated with disability; the cut off level above 5.5 mg/dL might be adopted in pharmacological trials aiming at reducing the incidence and progression of disability by reducing SUA, and for identifying subjects at increased risk of disability.

What about the caregiver? A journey into Parkinson's disease following the burden tracks.

OBJECTIVES: To investigate caregivers and patients characteristics related to different dimensions of burden in Parkinson's disease (PD). METHODS: 55 pairs of PD patients and caregivers were recruited. The burden was evaluated with the Caregiver Burden Inventory (CBI). Multivariate analysis was applied to evaluate the impact of caregivers' and patients' characteristics on the varying aspects of burden. RESULTS: ADL score was the dominant predictor for the total score and all dimensions of CBI, except for the social burden, which is strongly predicted by the motor severity of PD. As one can easily imagine, the Total CBI decreases as the ADL score increases. DISCUSSION: An increased appreciation for characteristics of caregiver burden is a fundamental aspect of the patient's global evaluation. Clinicians may need to directly probe for these factors in the caregiver as they may not be elicited routinely.

Prevalence of Obsessive-Compulsive Symptoms in Elderly Parkinson Disease Patients: A Case-Control Study.

BACKGROUND: The clinical picture of obsessive-compulsive disorder encompasses a broad range of symptoms that are related to multiple psychological domains, including perception, cognition, emotion, and social relatedness. As obsessive-compulsive symptoms (OCS) frequently have an early onset, there are limited data about OCS in older populations (≥65 years) and, in particular, in elderly subjects with Parkinson disease (PD). OBJECTIVE: This study aimed to estimate the prevalence of OCS using a self-report measure (Obsessive-Compulsive Inventory-Revised) and to identify associated sociodemographic and clinical factors in a sample of elderly PD patients compared to a comparison group of similarly aged healthy volunteers. RESULTS: The mean age was 74 ± 6 years in the PD patients and 73 ± 7 years in the comparison group. The mean disease duration was 9.6 ± 5.8 years. Among the PD patients, 30.7% reported at least one OCS or a related disorder compared to 21.1% in the comparison group. Hoarding was significantly more common in PD patients than in the comparison group. CONCLUSIONS: Subclinical OCS were present at a high percentage in both PD patients and comparison group. The OCS phenotype in PD may present differently, as hoarding was more common in PD patients.

Safinamide as an adjunct therapy in older patients with Parkinson's disease: a retrospective study.

BACKGROUND: Safinamide, as a levodopa adjunct, is effective in reducing motor fluctuations in Parkinson's disease (PD) patients; however, scarce evidence is available regarding its use in older PD patients. AIM: To evaluate the safety and tolerability of safinamide as an adjunct therapy in patients aged ≥ 60 years with advanced PD. METHODS: A retrospective study including 203 PD patients admitted to a geriatric day hospital, who were evaluated following an extensive clinical protocol. Safinamide use was categorized as never used, ongoing, and withdrawn. Potential correlations of Safinamide withdrawal were investigated in stepwise backward logistic regression models. RESULTS: A total of 44 out of 203 participants were current or former users of Safinamide. Overall, 14 (32%) patients discontinued due to treatment-emergent adverse events (TEAEs). Withdrawal was not associated with older age. CONCLUSIONS: Safinamide as an adjunct therapy in patients aged ≥ 60 years with advanced PD was found to be safe and well-tolerated in older patients. There were no specific demographic or clinical characteristics associated with suspension.

Untangling the relationship between fat distribution, nutritional status and Parkinson's disease severity.

BACKGROUND: Parkinson's disease (PD) is responsible for significant changes in body composition. AIMS: We aimed to test the association between PD severity and fat distribution patterns, and to investigate the potential modifier effect of nutritional status in this association. METHODS: We enrolled 195 PD subjects consecutively admitted to a university geriatric day hospital. All participants underwent comprehensive clinical evaluation, including assessment of total and regional body composition (dual-energy X-ray absorptiometry, DXA), body mass index, nutritional status (Mini-Nutritional Assessment, MNA), motor disease severity (UPDRS III), comorbidities, and pharmacotherapy. RESULTS: The fully adjusted linear regression model showed a negative association between UPDRS III and total body fat in kg and percentage (respectively, B - 0.79; 95% CI - 1.54 to - 0.05 and B - 0.55; 95% CI - 1.04 to - 0.05), percentage android fat (B - 1.07; 95% CI - 1.75 to - 0.39), trunk-leg fat ratio (B - 0.02; 95% CI - 0.04 to - 0.01), trunk-limb fat ratio (B - 0.01; 95% CI - 0.06 to - 0.01) and android-gynoid fat ratio (B - 0.01; 95% CI - 0.03 to - 0.01). After stratification by MNA score, all the parameters of android-like fat distribution resulted negatively associated (p < 0.001 for all) with UPDRS III, but only among subjects with a MNA < 23.5 (risk of malnutrition or malnutrition). CONCLUSION: We found a negative association between severity of motor impairment and total fat mass in PD, more specific with respect to an android pattern of fat distribution. This association seems to be driven by nutritional status, and is significant only among patients at risk of malnutrition or with overt malnutrition.

Recovery Time after Hemodialysis Is Inversely Associated with the Ultrafiltration Rate.

INTRODUCTION: The present study aimed to determine the variables that are associated with a longer dialysis recovery time (DRT) and to define the relationship that exists between DRT and the ultrafiltration rate (UFR) in prevalent chronic hemodialysis (CHD) patients. METHODS: We studied 210 prevalent CHD of 5 hemodialysis units in Central Italy. Patients were invited to answer to the question: "How long does it take you to recover from a dialysis session?" Answers to this question were subsequently converted into minutes. Demographic, clinical and laboratory parameters were recorded for each patient as well as the UFR (mL/kg/h), the dialysate sodium concentration and temperature. RESULTS: Median DRT was 180 min (60-420). Ninety five (45%) patients had a DRT ≥ the median value. Mean UFR was 9.2 ± 3.0 mL/kg/h. Patients with a lower DRT had a less prevalent disability in the instrumental activities daily living, had a higher UFR, and a lower dialysate temperature, as compared with subjects with higher DRT. According to the logistic regression model, UFR was associated with a DRT below the median (i.e., 180) in the unadjusted model (OR 1.12; 95% CI 1.02-1.23; p = 0.019), after adjusting for age and sex (OR 1.11; 95% CI 1.01-1.22; p = 0.025), and in the fully adjusted model (OR 1.11; 95% CI 1.04-1.22; p = 0.040). UFR increase was associated with increasing probability of DRT below the median (p for trend = 0.035). The highest tertile of DRT was associated with UFR below the mean value (i.e., 9.2 mL/kg/h) in multinomial logistic regression having the lowest DRT tertile as reference. DRT was significantly lower in patients with UFR > 13 mL/kg/h than in patients with UFR 10-13 or < 10 mL/kg/h. CONCLUSION: DRT is inversely associated with UFR in CHD patients. Whether a high UFR should be recommended to reduce the DRT needs to be elucidated through an adequate prospective randomized study.

Definition of a Geriatric Depression Scale cutoff based upon quality of life: a population-based study.

OBJECTIVES: The cutoff scores for the Geriatric Depression Scale (GDS) commonly adopted in clinical and research settings are based upon other neuropsychological tests. However, any intervention for depression should aim at improving subjective quality of life (QoL). We searched for a GDS cutoff level that might identify a decrease in perceived QoL using a scale that also allows formal cost-effectiveness calculations. METHODS: Quality of life was assessed by the Health Utilities Index, Mark 3 in all 344 residents of Tuscania (Italy) aged 75 years and above. Mood was assessed by both the 30-item GDS and the derived 15-item GDS. The association of GDS with low QoL was analyzed by multivariable logistic regression. Receiver operating characteristic curve analysis was adopted to estimate the overall predictive value and the best GDS cutoff for poor QoL. RESULTS: The 30-item GDS score was associated with increased probability of a worse QoL (odds ratio (OR) = 1.07, 95% confidence (CI) = 1.02-1.12, p = 0.003); also, it was a fair predictor of worse QoL (area under the curve (AUC) = 0.72; 95% CI = 0.67-0.76). The best GDS score cutoff for identifying a poor QoL was above 9/30. Results were similar (OR = 1.07, 95% CI = 1.02-1.12, p = 0.003, and AUC = 0.72, 95% CI = 0.67-0.76) for the short GDS form for a cutoff above 5/15. CONCLUSIONS: Among older subjects, depressive symptoms are associated with reduced QoL; GDS scores above 9/30 or 5/15 best predict poor perceived health-related QoL. These cutoff scores could therefore identify subjects in whom treatment is more likely to improve QoL and to yield a favorable cost-effectiveness ratio. Copyright © 2017 John Wiley & Sons, Ltd.

Use of proton-pump inhibitors is associated with depression: a population-based study.

Treatment with proton-pump inhibitors (PPIs) might be associated with neuropsychological side effects. We examined the association between use of PPIs and depressive symptoms in an elderly population. Mood was assessed by the 30-item Geriatric Depression Scale (GDS) in all 344 inhabitants of Tuscania (Italy) aged 75 years and over, without exclusion criteria; depression was defined by a GDS score ≥11. Use of PPIs was associated with a higher GDS score in linear regression analysis (B = 2.43; 95% CI = 0.49-4.38; p = 0.014) after adjusting; also, use of PPIs was associated with increased adjusted probability of depression in logistic regression (OR = 2.38; 95% CI = 1.02-5.58; p = 0.045). Higher PPIs dosages were associated with increased probability of depression (p for trend = 0.014). This association was independent of the diagnosis of peptic disease, as well as the use of antidepressant medications. No association was found between use of H2-blockers or antacids and the GDS score. Calculation of the population attributable risk indicated that 14% of depression cases could be avoided by withdrawal of PPIs. Use of PPIs might represent a frequent cause of depression in older populations; thus, mood should be routinely assessed in elderly patients on PPIs.

The role of cognitive reserve in cognitive aging: what we can learn from Parkinson's disease.

Parkinson's disease (PD) typically occurs in elderly people and some degree of cognitive impairment is usually present. Cognitive reserve (CR) theory was proposed to explain the discrepancy between the degree of brain pathologies and clinical manifestations. We administered a comprehensive neuropsychological battery to 35 non-demented participants affected by PD. All participants underwent also the Cognitive Reserve Index questionnaire and the Brief Intelligence Test as proxies for CR. Relationships between CR and cognitive performance were investigated by linear regression analyses, adjusting for significant confounding factors. At linear regression analyses, higher CR scores were independently associated with a better performance on Word Fluency (p ≤ 0.04) and Digit Span (backward) (p ≤ 0.02); no associations were observed between CR and other cognitive tests. Our data provide empirical support to the relation between CR and cognitive impairment in PD. In particular, this study suggests that CR may have greater effects on the cognitive areas mostly affected in PD as executive functions.

Functional impairment is associated with an increased risk of mortality in patients on chronic hemodialysis.

BACKGROUND: Functional impairment is associated with adverse outcomes in older people, as well as in patients on chronic hemodialysis. The aim of the present study was to determine the characteristics associated with functional impairment in chronic hemodialysis, and to evaluate if functional impairment represents a risk factor for reduced survival in chronic hemodialysis. METHODS: All 132 chronic hemodialysis referring to the Hemodialysis Service of the Catholic University, Rome, Italy between November 2007 and May 2015 were included. All patients underwent comprehensive geriatric assessment; functional ability was estimated using two questionnaires exploring independency in bathing, dressing, toileting, transferring, continence, feeding (ADLs), and independency in using the telephone, shopping, food preparation, housekeeping, laundering, traveling, taking medications, and handling finances (IADLs). Functional impairment was diagnosed in presence of dependence in one or more ADLs/IADLs. Mood was assessed using the 30-item Geriatric Depression Scale. Logistic regression was used to evaluate factors associated with functional impairment. The association between functional impairment and survival was assessed by Cox regression. RESULTS: ADLs impairment was present in 34 (26 %) participants, while IADLs impairment was detected in 64 (48 %) subjects. After a follow up of 90 months, 55 (42 %) patients died. In logistic regression, depressive symptoms were associated with ADLs and IADLs impairment (OR 1.12; 95 % CI = 1.02-1.23; OR 1.16; 95 % CI = 1.02-1.33; respectively). In Cox regression, ADLs impairment was associated with mortality (HR 2.47; 95 % CI-1.07-5.67) while IADLs impairment was not associated with reduced survival (HR .80; 95 % CI-.36-1.76). CONCLUSIONS: Functional impairment is associated with depressive symptoms; also, impairment in the ADLs represents a risk factor of reduced survival in chronic hemodialysis. These associations and their potential implication should be assessed in dedicated studies.

Disability is associated with emergency room visits in the elderly: a population-based study.

BACKGROUND: Emergency room (ER) visits and hospitalizations of elderly subjects with chronic comorbidities, often disabled, are increasing. AIMS: The aim of the present study was to assess whether among older subjects functional disability is associated with increased ER visits and hospitalization rates. METHODS: We assessed the association of functional ability with 1-year ER visits and hospitalization rates in all 342 subjects aged 75+ living in Tuscania (Italy) in 2004. Functional ability was estimated using the Katz' activities of daily living (ADLs), and the Lawton and Brody scale for the instrumental activities of daily living (IADLs). Functional disability was defined as the dependence for two or more ADLs or IADLs. RESULTS: According to Cox regression, disability in ADLs was associated with increased risk of ER visits (RR 2.12; 95 % CI 1.11-4.08; P = .023) but not of hospital admission (RR 1.50; 95 % CI .80-2.80; P = .208). Also, in Poisson regression, ADLs disability predicted the number of ER visits (IRR 2.56; 95 % CI 1.48-4.40; P = .001). DISCUSSION: Disability is associated with increased risk of ER visits, but not of subsequent hospitalization in community-dwelling elderly, independent of clinical conditions. Dedicated studies are needed to evaluate the impact of social interventions for disabled elderly on ER access rates. CONCLUSIONS: Emergency Departments should implement innovative triage procedures to identify older patients with disability who gain access to ER, to recognize and classify any unmet social needs.

Dopaminergic agents and nutritional status in Parkinson's disease.

BACKGROUND: Malnutrition has been found in up to 24% of patients with Parkinson's disease; dopaminergic drugs might impair nutritional status. We evaluated the association of nutritional status with the use of dopaminergic agents. METHODS: We analyzed data from 75 elderly patients with Parkinson's disease attending a geriatric day hospital. Nutritional status was assessed by the Mini Nutritional Assessment (MNA). Dopaminergic drugs were normalized for weight. RESULTS: In linear regression, total levodopa (l-dopa) equivalent daily dose (LEDD) was associated with worse MNA (B = -0.14, 95% CI = -0.26--0.02; P = 0.019). This association remained significant only for l-dopa (B = -0.19, 95% CI = -0.32--0.52; P = 0.007), but not dopaminergic agent dosages. Increasing l-dopa dosages were associated with increasing probability of risk of malnutrition (P for trend = 0.049). CONCLUSIONS: In our population, LEDD was associated with worse nutritional status and risk of malnutrition; this association was limited to use of l-dopa.

Cognitive performance is associated with left ventricular function in older chronic hemodialysis patients: result of a pilot study.

BACKGROUND: Cognitive impairment is a common finding in end-stage renal disease patients on chronic hemodialysis, but data on the associated factors are still scanty. AIMS: The present study evaluated the association between cognitive function and left ventricular systolic function in hemodialysis patients. METHODS: We enrolled 72 patients admitted to the Hemodialysis Unit of the Catholic University, Rome. Cognitive performance was evaluated using the Mini Mental State Examination (MMSE); a cutoff of 24 was used to diagnose cognitive impairment. Left ventricular ejection fraction (LVEF) was assessed by echocardiography. Multivariable linear and logistic regressions were adopted to assess the adjusted association between cognitive performance and LVEF. Also, linear discriminant analysis was performed to ascertain the cutoff level of LVEF which best predicted cognitive impairment. RESULTS: Cognitive impairment was found in 37 (51 %) patients. According to linear regression, MMSE was independently associated with LVEF (B = 0.06; 95 % CI = 0.01-0.12; P = 0.040). Logistic regression confirmed the inverse association between LVEF and cognitive impairment (OR = 0.87; 95 % CI = 0.78-0.98; P = 0.022). In linear discriminant analysis, the LVEF cutoff level that best predicted cognitive impairment was ≤51 %. CONCLUSION: Cognitive impairment is a common finding in hemodialysis patients. Even mildly depressed LVEF is independently associated with cognitive impairment. This association and its potential therapeutic implications should be assessed in dedicated studies.

Recent Advances and Future Directions in Syncope Management: A Comprehensive Narrative Review.

Syncope is a highly prevalent clinical condition characterized by a rapid, complete, and brief loss of consciousness, followed by full recovery caused by cerebral hypoperfusion. This symptom carries significance, as its potential underlying causes may involve the heart, blood pressure, or brain, leading to a spectrum of consequences, from sudden death to compromised quality of life. Various factors contribute to syncope, and adhering to a precise diagnostic pathway can enhance diagnostic accuracy and treatment effectiveness. A standardized initial assessment, risk stratification, and appropriate test identification facilitate determining the underlying cause in the majority of cases. New technologies, including artificial intelligence and smart devices, may have the potential to reshape syncope management into a proactive, personalized, and data-centric model, ultimately enhancing patient outcomes and quality of life. This review addresses key aspects of syncope management, including pathogenesis, current diagnostic testing options, treatments, and considerations in the geriatric population.

[Gender discrepancy: time to implement gender-based clinical management]. / Position paper ANMCO: Differenze di genere nell'approccio farmacologico cardiovascolare.

It is well established that gender strongly influences cardiovascular risk factors, playing a crucial role in cardiovascular prevention, clinical pathways, diagnostic approach and treatment. Beyond the sex, which is a biological factor, gender entails a socio-cultural condition that impacts access and quality of care due to structural and institutional barriers. However, despite its great importance, this issue has not been adequately covered. Indeed sex and gender differences scarcely impact the clinical approach, creating a lot of disparities in care and outcomes of patients. Therefore, it becomes essential to increase the awareness of the importance of sex and gender influences on cardiovascular diseases. Moreover, new strategies for reducing disparities should be developed. Importantly, these differences should be taken into account in guideline recommendations. In this regard, it is crucial to include a greater number of women in clinical trials, since they are currently underrepresented. Furthermore, more women should be involved as member of international boards in order to develop recommendations and guidelines with more attention to this important topic.The aim of this ANMCO position paper is to shed light on gender differences concerning many cardiovascular drugs in order to encourage a more personalized therapeutic approach.

Metabolic syndrome and quality of life in the elderly: age and gender differences.

PURPOSE: The metabolic syndrome (MetS) is highly prevalent in Western older populations. MetS is an intriguing entity, because it includes potentially reversible risk factors. Some studies have suggested an inverse correlation between MetS and health-related quality of life (HRQoL), but data regarding older subjects are scanty and conflicting. The aim of this study was to assess the association between HRQoL and MetS in older, unselected community-dwelling subjects. METHODS: We analyzed data of 356 subjects aged 75+ living in Tuscania (Italy). HRQoL was assessed using the Health Utilities Index, Mark 3. Diagnosis of MetS was defined according to the National Cholesterol Education Program's ATP-III criteria. RESULTS: MetS was reported by 137 (38%) participants. According to linear regression analysis, MetS was associated with significantly better HRQoL in men (B = 0.19 95% CI = 0.06-0.32; p = 0.006), but not in women. Also, when the regression model was analyzed in men, MetS was associated with better HRQoL (B = 0.17, 95% CI = 0.01-0.32; p = 0.035) only among participants aged 80+. No significant associations were found in men between HRQoL and any of the single components of MetS. CONCLUSIONS: MetS is not associated with worse HRQoL among community-dwelling elderly; it is associated with significantly better HRQoL among the oldest men.