Built environment impact on people with dementia (PwD) health and well-being outcomes: a systematic review of the literature.

BACKGROUND AND AIM: The number of People with Dementia (PwD) is rising worldwide and represents a complex figure because of the changes in the cognitive sphere, altering perceptions of the Built Environment (BE). Even though the role of the built environment in the health and well-being of people it's nowadays well known, few studies analyze and evaluate the impact of specific Architectural Features. To this end, this contribution provides a systematic review that will underline the impacts of BE on the Health and Well-being of PwD and set a matrix of the relationship with measurable outcomes. METHODS: A literature review has been conducted on scientific databases. 40 studies that relate health outcomes and aspects of the built environment have been identified and organized on a comparison matrix that clearly shows the relationships between Architectural Features of BE and Health and Wellbeing Outcome. This matrix allows to identify which are the aspects that can impact on PwD as well as possible lacks. RESULTS: Many aspects appear to be widely explored, such as BPSD or wandering. In addition, significant gaps in the relationship between recognized aspects of the built environment recognized as relevant to the well-being of people with dementia and the real impacts on health outcomes such as the location and personalization of spaces. CONCLUSIONS: This study collected the most recent studies to underline the relationship between BE and dementia, providing a set of outcomes and architectural features that can be analyzed to assess the quality of BE for PwD.

Radiological assessment of dementia: the Italian inter-society consensus for a practical and clinically oriented guide to image acquisition, evaluation, and reporting.

BACKGROUND: Radiological evaluation of dementia is expected to increase more and more in routine practice due to both the primary role of neuroimaging in the diagnostic pathway and the increasing incidence of the disease. Despite this, radiologists often do not follow a disease-oriented approach to image interpretation, for several reasons, leading to reports of limited value to clinicians. In our work, through an intersocietal consensus on the main mandatory knowledge about dementia, we proposed a disease-oriented protocol to optimize and standardize the acquisition/evaluation/interpretation and reporting of radiological images. Our main purpose is to provide a practical guideline for the radiologist to help increase the effectiveness of interdisciplinary dialogue and diagnostic accuracy in daily practice. RESULTS: We defined key clinical and imaging features of the dementias (A), recommended MRI protocol (B), proposed a disease-oriented imaging evaluation and interpretation (C) and report (D) with a glimpse to future avenues (E). The proposed radiological practice is to systematically evaluate and score atrophy, white matter changes, microbleeds, small vessel disease, consider the use of quantitative measures using commercial software tools critically, and adopt a structured disease-oriented report. In the expanding field of cognitive disorders, the only effective assessment approach is the standardized disease-oriented one, which includes a multidisciplinary integration of the clinical picture, MRI, CSF and blood biomarkers and nuclear medicine.

Dementia Clinical Care in Relation to COVID-19.

PURPOSE OF REVIEW: This review discusses the complex relationship between COVID-19 and dementia and how the pandemic has affected the management of patients with dementia. This population resulted particularly susceptible to SARS-CoV-2 infection and its effects and also to the negative effects of the measures taken worldwide to control the spread of the virus. RECENT FINDINGS: Patients with dementia were at increased risk for COVID-19 compared to patients without dementia, and diagnosis of dementia represents an independent risk factor for hospitalization in COVID-19 patients. Mortality due to SARS-CoV2 infection in subjects with dementia is 2-5 times higher than in the general population. Cognitive impairment and delirium have been described in COVID-19 survivors. SARS-COV2 pandemic exacerbates the vulnerability of dementia patients and their caregivers, due to the morbidity and mortality from COVID-19, the indirect effects of the pandemic on the social supports, and the effects on healthcare system on which they depend. SUMMARY: The COVID-19 pandemic requires people with dementia to move from traditional models of health care to innovative models for home care, to support caregivers' burden, and to improve long term care.

Congestive heart failure and comorbidity as determinants of colorectal cancer perioperative outcomes.

There has been an increase in surgical interventions in frailer elderly with concomitant chronic diseases. The purpose of this paper was to evaluate the impact of aging and comorbidities on outcomes in patients who underwent surgery for the treatment of colorectal cancer (CRC) in Veneto Region (Northeastern Italy). This is a retrospective cohort study in patients ≥ 40 years who underwent elective or urgent CRC surgical resection between January 2013 and December 2015. Independent variables included: age, sex, and comorbidities. We analyzed variables associated with the surgical procedure, such as stoma creation, hospitalization during the year before the index surgery, the surgical approach used, the American Society of Anesthesiologists (ASA) score, and the Charlson Comorbidity Index score. Eight thousand four hundred and forty-seven patients with CRC underwent surgical resection. Patient age affected both pre- and post-resection LOS as well as the overall survival (OS); however, it did not affect the 30-day readmission and reoperation rates. Multivariate analysis showed that age represented a risk factor for longer preoperative and postoperative LOS as well as for 30-day and 365-day mortality, but it was not associated with an increased risk of 30-day reoperation and 30-day readmission. Chronic Heart Failure increased the 30-day mortality risk by four times, the preoperative LOS by 51%, and the postoperative LOS by 33%. Chronic renal failure was associated with a 74% higher 30-day readmission rate. Advanced age and comorbidities require a careful preoperative evaluation and appropriate perioperative management to improve surgical outcomes in older patients undergoing elective or urgent CRC resection.

Interventions for reducing loneliness: An umbrella review of intervention studies.

Loneliness is a common phenomenon associated with several negative health outcomes. Current knowledge regarding interventions for reducing loneliness in randomised controlled trials (RCTs) is conflicting. The aim of the present work is to provide an overview of interventions to reduce loneliness, using an umbrella review of previously published systematic reviews and meta-analyses. We searched major databases from database inception to 31 March 2020 for RCTs comparing active versus non-active interventions for reducing loneliness. For each intervention, random-effects summary effect size and 95% confidence intervals (CIs) were calculated. For significant outcomes (p-value < 0.05), the GRADE (Grading of Recommendations Assessment, Development and Evaluation) tool was used, grading the evidence from very low to high. From 211 studies initially evaluated, seven meta-analyses for seven different types of interventions were included (median number of RCTs: 8; median number of participants: 600). Three interventions were statistically significant for reducing loneliness, that is, meditation/mindfulness, social cognitive training and social support. When applying GRADE criteria, meditation/mindfulness (mean difference, MD = -6.03; 95% CI: -9.33 to -2.73; very low strength of the evidence), social cognitive training (8 RCTs; SMD = -0.49; 95% CI: -0.84 to -0.13; very low strength of the evidence) and social support (9 RCTs; SMD = -0.13; 95% CI: -0.25 to -0.01; low strength of the evidence) significantly decreased the perception of loneliness. In conclusion, three intervention types may be utilised for reducing loneliness, but they are supported by a low/very low certainty of evidence indicating the need for future large-scale RCTs to further investigate the efficacy of interventions for reducing loneliness.

Delirium: Clinical Presentation and Outcomes in Older COVID-19 Patients.

The aim of the study is to describe the clinical characteristics and outcomes of a series of older patients consecutively admitted into a non-ICU ward due to SARS-CoV-2 infection (14, males 11), developing delirium. Hypokinetic delirium with lethargy and confusion was observed in 43% of cases (6/14 patients). A total of eight patients exhibited hyperkinetic delirium and 50% of these patients (4/8) died. The overall mortality rate was 71% (10/14 patients). Among the four survivors we observed two different clinical patterns: two patients exhibited dementia and no ARDS (acute respiratory distress syndrome), while the remaining two patients exhibited ARDS and no dementia. The observed different clinical patterns of delirium (hypokinetic delirium; hyperkinetic delirium with or without dementia; hyperkinetic delirium with or without ARDS) identified patients with different prognosis: we believe these observations may have an impact on the management of older subjects with delirium due to COVID-19.

Correction to: Perioperative Management of Elderly patients (PriME): recommendations from an Italian intersociety consensus.

The article Perioperative Management of Elderly patients (PriME).

The impact of COVID-19 on health status of home-dwelling elderly patients with dementia in East Lombardy, Italy: results from COVIDEM network.

BACKGROUND: COVID-19 outbreak has led to severe health burden in the elderly. Age, morbidity and dementia have been associated with adverse outcome. AIMS: To evaluate the impact of COVID-19 on health status in home-dwelling patients. METHODS: 848 home-dwelling outpatients with dementia contacted from April 27 to 30 and evaluated by a semi-structured interview to evaluate possible health complication due to COVID-19 from February 21 to April 30. Age, sex, education, clinical characteristics (including diagnosis of dementia) and flu vaccination history were obtained from previous medical records. Items regarding change in health status and outcome since the onset of the outbreak were collected. COVID-19 was diagnosed in patients who developed symptoms according to WHO criteria or tested positive at nasal/throat swab if hospitalized. Unplanned hospitalization, institutionalization and mortality were recorded. RESULTS: Patients were 79.7 years old (SD 7.1) and 63.1% were females. Ninety-five (11.2%) patients developed COVID-19-like symptoms. Non COVID-19 and COVID-19 patients differed for frequency of diabetes (18.5% vs. 37.9%, p < 0.001), COPD (7.3% vs. 18.9%, p < 0.001), and previous flu vaccination (56.7% vs. 37.9%, p < 0.001). Diabetes and COPD were positively associated with COVID-19, whereas higher dementia severity and flu vaccination showed an inverse association. Among COVID-19 patients, 42 (44.2%) were hospitalized while 32 (33.7%) died. Non COVID-19 patients' hospitalization and mortality rate were 1.9% and 1.2%, respectively. COVID-19 and COPD were significantly associated with the rate of mortality. DISCUSSION/CONCLUSIONS: A high proportion of adverse outcome related to COVID-19 was observed in home-dwelling elderly patients with dementia. Active monitoring though telehealth programs would be useful particularly for those at highest risk of developing COVID-19 and its adverse outcomes.

Perioperative Management of Elderly patients (PriME): recommendations from an Italian intersociety consensus.

BACKGROUND: Surgical outcomes in geriatric patients may be complicated by factors such as multiple comorbidities, low functional performance, frailty, reduced homeostatic capacity, and cognitive impairment. An integrated multidisciplinary approach to management is, therefore, essential in this population, but at present, the use of such an approach is uncommon. The Perioperative Management of Elderly patients (PriME) project has been established to address this issue. AIMS: To develop evidence-based recommendations for the integrated care of geriatric surgical patients. METHODS: A 14-member Expert Task Force of surgeons, anesthetists, and geriatricians was established to develop evidence-based recommendations for the pre-, intra-, and postoperative care of hospitalized older patients (≥ 65 years) undergoing elective surgery. A modified Delphi approach was used to achieve consensus, and the strength of recommendations and quality of evidence was rated using the U.S. Preventative Services Task Force criteria. RESULTS: A total of 81 recommendations were proposed, covering preoperative evaluation and care (30 items), intraoperative management (19 items), and postoperative care and discharge (32 items). CONCLUSIONS: These recommendations should facilitate the multidisciplinary management of older surgical patients, integrating the expertise of the surgeon, the anesthetist, the geriatrician, and other specialists and health care professionals (where available) as needed. These roles may vary according to the phase and setting of care and the patient's conditions.

Medico-legal assessment of personal damage in older people: report from a multidisciplinary consensus conference.

Ageing of the global population represents a challenge for national healthcare systems and healthcare professionals, including medico-legal experts, who assess personal damage in an increasing number of older people. Personal damage evaluation in older people is complex, and the scarcity of evidence is hindering the development of formal guidelines on the subject. The main objectives of the first multidisciplinary Consensus Conference on Medico-Legal Assessment of Personal Damage in Older People were to increase knowledge on the subject and establish standard procedures in this field. The conference, organized according to the guidelines issued by the Italian National Institute of Health (ISS), was held in Bologna (Italy) on June 8, 2019 with the support of national scientific societies, professional organizations, and stakeholders. The Scientific Technical Committee prepared 16 questions on 4 thematic areas: (1) differences in injury outcomes in older people compared to younger people and their relevance in personal damage assessment; (2) pre-existing status reconstruction and evaluation; (3) medico-legal examination procedures; (4) multidimensional assessment and scales. The Scientific Secretariat reviewed relevant literature and documents, rated their quality, and summarized evidence. During conference plenary public sessions, 4 pairs of experts reported on each thematic area. After the last session, a multidisciplinary Jury Panel (15 members) drafted the consensus statements. The present report describes Conference methods and results, including a summary of evidence supporting each statement, and areas requiring further investigation. The methodological recommendations issued during the Conference may be useful in several contexts of damage assessment, or to other medico-legal evaluation fields.

A two-year multicenter point prevalence study of older patients with hip fractures admitted to rehabilitation units in Italy.

PURPOSE: To date in Italy we do not have sufficient information on the rehabilitation process of older patients with hip fractures especially in the context of dementia. The main aims of the study were to gather information on the characteristics of older patients with hip fracture admitted to rehabilitation units with a specific focus on geriatric syndromes and the rehabilitation process. METHODS: A national multi-center "point prevalence study" was conducted in Italy over two index days in 2017 and 2018. All patients aged 70 years and older hospitalized on the index day in Rehabilitation Units after a hip fracture were eligible. RESULTS: A total of 615 patients were included. Most of the hospitals involved were from northern Italy, to a lesser extent from central and from southern Italy. The mean age was 83.08 ± 7.9 years. Almost half of the patients lived alone before the hip fracture. Most of the falls happened at home and while walking. The prevalence of delirium, dementia and malnutrition was 9.1%, 36.6%, and 19.3%, respectively. Antidepressants were prescribed in 27% of the population. The multidisciplinary team was activated as follows: occupational therapist in 18.9% of the cases, psychologists in 14.5%, social workers in 15.3%, and speech therapists in 6.5%. CONCLUSION: The study allowed the collection of data on a relatively large sample of older patients with hip fracture showing the possible current limitations in the correct management of geriatric syndromes in this frail population. Future multicenter longitudinal studies are required to further study this population.

Improving the care of older patients during the COVID-19 pandemic.

The SARS-CoV-2 pandemic has led to a dramatic crisis of Health Care Systems worldwide, and older people have been among the most disadvantaged. Specific recommendations and reports have been released both at International and National level, regarding the diagnosis and management of COVID-19 in the elderly. However, little has been proposed for an appropriate response to older, frail and multimorbid patients in different settings of care (acute care units, long term care facilities, nursing homes and primary care) and for the management of geriatric syndromes (i.e. delirium, sarcopenia, falls). We presume that the current pandemic of will leads to substantial changes in health care systems, and we suggest some key guide principles that could inspire the provision of healthcare services to older people and their families. These principles are primarily directed to physicians and nurses working in the geriatric field but could also be useful for other specialists.

Factors Associated With Loneliness: An Umbrella Review Of Observational Studies.

BACKGROUND: Evidence provides inconsistent findings on risk factors and health outcomes associated with loneliness. The aim of this work was to grade the evidence on risk factors and health outcomes associated with loneliness, using an umbrella review approach. METHODS: For each meta-analytic association, random-effects summary effect size, 95% confidence intervals (CIs), heterogeneity, evidence for small-study effect, excess significance bias and 95% prediction intervals were calculated, and used to grade significant evidence (p<0.05) from convincing to weak. For narrative systematic reviews, findings were reported descriptively. RESULTS: From 210 studies initially evaluated, 14 publications were included, reporting on 18 outcomes, 795 studies, and 746,706 participants. Highly suggestive evidence (class II) supported the association between loneliness and incident dementia (relative risk, RR=1.26; 95%CI: 1.14-1.40, I2 23.6%), prevalent paranoia (odds ratio, OR=3.36; 95%CI: 2.51-4.49, I2 92.8%) and prevalent psychotic symptoms (OR=2.33; 95%CI: 1.68-3.22, I2 56.5%). Pooled data supported the longitudinal association between loneliness and suicide attempts and depressive symptoms. In narrative systematic reviews, factors cross-sectionally associated with loneliness were age (in a U-shape way), female sex, quality of social contacts, low competence, socio-economic status and medical chronic conditions. LIMITATIONS: Low quality of the studies included; mainly cross-sectional evidence. CONCLUSIONS: This work is the first meta-evidence synthesis showing that highly suggestive and significant evidence supports the association between loneliness and adverse mental and physical health outcomes. More cohort studies are needed to disentangle the direction of the association between risk factors for loneliness and its related health outcomes.

COVID-19 and the Fears of Italian Senior Citizens.

Italy has been hit very hard by the severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) pandemic. This brief report highlights some of the peculiarities manifested by its older adult population, with particular reference to those living in nursing institutions and at home. Mortality data (as of 26 April) are reported, together with reactions to forced isolation, loneliness, and fear of contracting the disease, which represent big challenges for all, especially for frail elderly people.

Preliminary investigation of predictors of distress in informal caregivers of patients with delirium superimposed on dementia.

OBJECTIVE: Delirium superimposed on dementia (DSD) is common and associated with adverse outcomes. Current evidence indicates that some patients with dementia may recall delirium with distress for them and their caregivers. The aim of this study is to identify predictors of distress in informal caregivers of older patient with DSD. METHODS: A total of 33 caregivers of 33 patients with DSD were interviewed 3 days after the resolution of delirium (T0) and at 1-month follow-up (T1) to describe their level of distress related to the delirium episode. A linear regression was used to identify predictors of caregivers' distress at T0 and T1 defined a priori: age, sex, level of education, employment status, delirium subtypes, delirium severity, type and severity of dementia, and the time spent with the patient during the delirium episode. RESULTS: Caregivers were mostly female (81%), 59 (± 13.0) years old on average. The predictors of distress at T0 were the patient's severity of both dementia and delirium. Moderate dementia was associated with lower distress, whereas higher delirium severity was associated with greater distress. At 1-month follow-up, the predictors of distress were the age of caregiver and time spent in care; the distress level was higher when caregivers were older, and they spent less time with their loved one. CONCLUSIONS: These preliminary findings underline the importance of providing continuous training and support for the caregivers, especially in coping strategies, in order to improve the care of DSD patients and prevent the caregivers' distress in long time period.

Delirium in patients with dementia and in children: Overlap of symptoms profile and possible role for future diagnosis.

BACKGROUND: Delirium in the extremes of the age spectrum may show similarities in presentations, and these similarities may provide information to develop tools for the diagnosis of delirium superimposed on dementia (DSD). We sought to investigate the symptom profile and subtypes of delirium in patients with dementia, and in infants and preschool children. METHODS: This was an exploratory analysis of previous prospective cohort studies that evaluated delirium with the DSM-IV criteria in patients with dementia, and in critically ill infants (< 2 years of age) and preschool children (2-5 years of age), respectively. Delirium subtypes were defined based on the Richmond Agitation-Sedation Scale. RESULTS: We included 147 patients, 35 adult patients with delirium DSD, 80 infants, and 32 preschool children with delirium. Hypokinesia and apathy were common among both DSD (72%), infants (74%) and preschool children (75%) with delirium, whereas hallucinations and anxiety were less common in both adults with DSD (26%) and infants (10%) and preschool children (14%). Hypoactive delirium was most common delirium subtype among infants (68%) and preschoolers (76%), whereas RASS = 0 (alert) delirium was the most common among adult patients with DSD (55%). CONCLUSIONS: The study reports similarities in the symptoms profile of delirium in a cohort of patients with dementia and delirium, and in infants and preschool-aged children with delirium. These preliminary findings might be informative to design future studies adapting delirium assessments used in in infants and preschool-aged children to patients with dementia, especially in the moderate to severe stages.