Impact of potentially inappropriate medications and polypharmacy on 3-month readmission among older patients discharged from acute care hospital: a prospective study.

BACKGROUND: Polypharmacy and potentially inappropriate medications (PIMs) are known to affect several negative outcomes in older patients. However, studies comparatively assessing polypharmacy and PIMs in relation to readmission are distinctively lacking. AIMS: To compare the impact of polypharmacy and PIMs on 3-month readmission among older patients discharged from acute care hospital. METHODS: Our series consisted of 647 patients consecutively enrolled in a multicenter observational study. The outcome of the study was the occurrence of any admission during the 3-month follow-up after discharge. Polypharmacy was defined as use of more than eight medications. PIMs were identified using 2015 version of Beers and Screening Tool of Older Persons Prescriptions (STOPP) criteria. Statistical analysis was performed using logistic regression models. RESULTS: After adjusting for potential confounders, polypharmacy (OR 2.72, 95% CI 1.48-4.99) was found associated with the outcome, while Beers (OR 0.85, 95% CI 0.46-1.56), STOPP (OR 1.60, 95% CI 0.85-3.01), or combined Beers and STOPP violations (OR 0.99, 95% CI 0.57-1.74) were not. The association between polypharmacy and 3-month readmission was confirmed in logistic regression models including Beers (OR 2.88, 95% CI 1.55-5.34), STOPP (OR 2.64, 95% CI 1.43-4.87), or combined Beers and STOPP violations (OR 2.80, 95% CI 1.51-5.21). DISCUSSION: Besides confirming that polypharmacy should be considered as a marker for readmission risk among older patients discharged from acute care hospital, our findings suggest that the association between polypharmacy and 3-month readmission is substantially independent of use of PIMs. CONCLUSIONS: Polypharmacy, but not PIMs was significantly associated with readmission. Hospitalization should always be considered as a clue to individuate unnecessary polypharmacy and to reduce the burden of medications whenever possible.

Zinc improves the development of human CD34+ cell progenitors towards NK cells and increases the expression of GATA-3 transcription factor in young and old ages.

Aim of this study was to evaluate the effect of zinc on the kinetic of development of CD34(+) cell progenitors towards NK cells in young and old ages. CD34(+) cells were purified from peripheral blood of healthy subjects and cultured in medium supplemented with interleukin-15, interleukin-7, Flt 3 ligand, and stem cell factor. The number of cells developed in culture was significantly lower in old than in young subjects. CD34(+) cells progressively lost CD34 antigen with a faster kinetics in old than in young donors. The percentage of primitive double positive CD34(+)CD133(+) cells inside the purified CD34(+) cells was greatly lower in old than in young subjects. These cells progressively decreased in cultures from young subjects whereas they remained at very low levels in old donors. Cells developed in culture acquired a NK phenotype mainly characterized by CD56(+)CD16(-) cells in young subjects and CD56(-)CD16(+) cells in old donors. These NK cells exerted a lower cytotoxic activity in old than in young subjects. The supplementation with zinc greatly increased the number of cells in culture and the percentage and the cytotoxic activity of NK cells both in young and old ages. In zinc supplemented cultures, a 3.6-fold and a 4.1-fold increased expression of GATA-3 transcription factor was observed in young and old donors, respectively. Our data demonstrate that zinc influences the proliferation and differentiation of CD34(+) progenitors both in young and old ages.

Reference values for CD4+ and CD8+ T lymphocytes with naïve or memory phenotype and their association with mortality in the elderly.

BACKGROUND: Well-established reference values which take into account the influence of age on immune cell phenotype, and the impact of naïve or memory T cells on mortality have not been well defined in the elderly. OBJECTIVE: The aim of this study was to evaluate the reference values for the peripheral number of total and naïve or memory CD4 and CD8 T cells in a healthy population in Italy, and to analyze whether the immune phenotype was associated with an increased risk of death among older adults. METHODS: The number of total or naïve and memory CD4+ or CD8+ T cells was evaluated in the peripheral blood of 288 healthy people ranging in age from 20 to 107 years. Furthermore, to correlate peripheral immune phenotype with mortality rate after a 3-years follow-up, a retrospective analysis was performed on the results from those individuals aged >65 years at the time of the enrollment in the study. RESULTS: The absolute number of total and naïve T cells was progressively reduced with increasing age in both the CD4+ and CD8+ T cell populations. The decrease was particularly evident for cells with naïve phenotype, since CD4-naïve and CD8-naïve T cells respectively showed a 4- and a 2- to 3-fold reduction in 70- to >90-year-old subjects in comparison with young adults. The number of CD4 memory T cells significantly increased with age. No significant age-related change was observed in the number of CD8+ memory T cells. Of the 194 subjects included in the study of association of immune phenotype with mortality, 121 were alive and 73 deceased during the 3-year follow-up. The impact of immune parameters on survival demonstrated that only the absolute number of CD8 memory T cells, after adjustment for age, correlated with increased mortality (OR 1.007, 95% CI 1.002-1.012, p = 0.01). The correlation was significant in female but not in male subjects. CONCLUSION: We provide reference values for total and naïve or memory CD4 and CD8 T cell populations, and demonstrate that the absolute number of CD8 memory T cells, after adjustment for age, correlates with increased mortality.

A polymorphism of the YTHDF2 gene (1p35) located in an Alu-rich genomic domain is associated with human longevity.

The uneven distribution of Alu repetitive elements in the human genome is related to specific functional properties of genomic regions. We report the identification of a locus associated with human longevity in one of the chromosomal regions with the highest density of Alu elements, in 1p35. The locus, corresponding to a (TG)n microsatellite in the YTHDF2 gene, was identified by characterizing an "anonymous" marker detectable through inter-Alu fingerprinting, which previously evidenced an increased homozygosity in centenarians. After genotyping 412 participants of different ages, including 137 centenarians, we confirmed the increased homozygosity in centenarians at this locus, and observed a concomitantly increased frequency of the most frequent allele and the corresponding homozygous genotype. Remarkably, the same genotype was associated with increased YTHDF2 messenger RNA levels in immortalized lymphocytes. Finally, YTHDF2 messenger RNA resulted to be mainly expressed in testis and placenta. The data suggest a possible role of this locus in human longevity.

Effect of hyperglycemia on the number of CD117+ progenitor cells and their differentiation toward endothelial progenitor cells in young and old ages.

Dysfunction of endothelial progenitor cells (EPCs) has been reported either in aging or diabetes, though the influence of an "old" environment on numerical and functional changes of diabetes associated EPCs is not known. We evaluated the effect of both aging and early stage of streptozotocin-induced diabetes on the number of bone marrow-derived CD117+ progenitor cells, and on their differentiation in vitro toward EPCs. The phenotype of progenitor cells and the uptake of acetylated-low density lipoprotein (Ac-LDL) were evaluated after cell culture in VEGF, FGF-1, and IGF-1 supplemented medium. Hyperglycemia similarly reduced the number of CD117+ cells both in young and old mice. CD117+ cells from young mice differentiated better than those from old animals "in vitro", with a greater reduction of CD117+ cells and an higher increase of CD184+VEGFR-2+ cells. In diabetic mice, in vitro CD117+ cells differentiation was significantly reduced in young animals. Diabetes did not impact on the scarce differentiation of CD117+ cells from old mice. Hyperglycemia reduced the uptake of acLDL by EPCs greatly in young than in old mice. These findings indicate that part of the EPCs functional alterations induced by hyperglicemia in young mice are observed in normal aged mice.

Special considerations for the treatment of chronic kidney disease in the elderly.

Chronic kidney disease (CKD) is common in older adults, and its burden is expected to increase in older populations. Even if the knowledge on the approach to older patient with CKD is still evolving, current guidelines for pharmacological management of CKD does not include specific recommendations for older patients. Additionally, decision-making on renal replacement therapy (RRT) for older patients is far from being evidence-based, and despite the improvement in dialysis outcomes, RRT may cause more harm than benefit compared with conservative care when prognostic stratification is not carefully assessed. The use of comprehensive geriatric assessment tools could help clinicians in applying a more informed decision-making. Finally, physical exercise and rehabilitation interventions also represents a promising therapeutic strategy.

In vitro IL-6 production by EBV-immortalized B lymphocytes from young and elderly people genotyped for -174 C/G polymorphism in IL-6 gene: a model to study the genetic basis of inflamm-aging.

In the present investigation we analysed Interleukin 6 (IL-6) in vitro production by Epstein-Barr virus (EBV)-immortalized B lymphocytes established from 43 subjects, 15 young people and 28 elderly people, including 18 centenarians, after 3, 6, 9, 24, 48 and 72 h of culture. The subjects were genotypized for the C to G transition at nucleotide -174 of IL-6 gene promoter (-174 C/G) and were classified as C allele carriers (C+) and non-carriers (C-). We found that: (i) the interindividual difference in in vitro IL-6 production was wider in elderly individuals in respect to young individuals, leading to different coefficient of variation in the two groups; (ii) the -174 C/G polymorphism had an age-related effect on IL-6 in vitro production. Only among C- people, cells from elderly subjects produced significant higher level of IL-6 than cells from young subjects. These data are consistent with our previous results regarding the IL-6 serum levels in a large group of people of different age, including centenarians. Thus, the EBV-immortalized B lymphocytes can be considered a useful in vitro model for studying the genetic control of IL-6 production and its changes with age.

The -174 C/G locus affects in vitro/in vivo IL-6 production during aging.

IL-6 in vitro production, as well as the serum/plasma concentration of the cytokine, increase with age. In the present investigation, a total of 62 individuals (31 males and 31 females), aged from 29 to 93 years of age (mean age of males: 60.4 years; mean age of females: 59.4 years) were assessed for IL-6 plasma concentration, and for IL-6 in vitro production, using supernatants of 4h cultured adherent peripheral blood mononuclear cells (aPBMC). The subjects were examined for a C to G transition at nucleotide -174 of the IL-6 gene promoter (-174 C/G locus), and were classified as C allele carriers (C+) or non-carriers (C-). We found that: (i) aPBMC from C+ individuals produced smaller amounts of IL-6 in vitro than C- individuals; (ii) IL-6 production by aPBMC increased with age in C+ but not in C- subjects; (iii) there was no correlation between IL-6 plasma levels and in vitro IL-6 production by aPBMC; (iv) IL-6 C+ individuals had lower plasma levels than C- individuals, and this phenomenon was significant only in men. On the whole our data indicate that the production of IL-6 is genetically controlled and age- and gender-dependent.

MtmRNA gene expression, via IL-6 and glucocorticoids, as potential genetic marker of immunosenescence: lessons from very old mice and humans.

Metallothioneins (MTs) are involved in metal-related cell homeostasis because of their high affinity for metals forming clusters. The main functional role of MTs is to sequester and/or dispense zinc participating in zinc homeostasis, which is relevant in normal immune response. Consistent with this role, MTs gene expression (MTmRNA) is transcriptionally induced by a variety of stressing agents to protect cells from reactive oxygen species. In order to accomplish this task, MTs gene expression is affected by glucocorticoids and IL-6 for a prompt immune response. This protection is peculiar in young-adult age during transient stress and inflammatory condition, but not in ageing because stress-like condition and inflammation are constant for the whole circadian cycle. This may lead MTs to turn-off from role of protection in young age to deleterious one in ageing. The aim is to suggest MTmRNA as potential genetic marker of immunosenescence. Liver MTmRNA, IL-6 and glucocorticoids levels are high, whereas the bioavailability of zinc ions is low and natural killer cells activity is depressed in old and very old mice during the light period as compared to young in the same period. An inversion of nutritional-endocrine-immune profile exclusively occurs in young mice during the night showing the existence of immune plasticity. No inversion occurs in old mice during the night. As a consequence, no immune plasticity in old mice ensues. By contrast, very old mice remodel the altered MTmRNA and immune-endocrine profile during the night up to values of young ones observed during the light period. Therefore, the remodelling of MTmRNA may be involved in the maintenance of immune plasticity with subsequent successful ageing. Thus, MTmRNA, via IL-6 and glucocorticoids, may be potential genetic marker of immunosenescence. This assumption is reinforced by low MTmRNA in lymphocytes of nonagenarians and young-adult people in comparison with elderly and Down's syndrome subjects.

Heat shock response by EBV-immortalized B-lymphocytes from centenarians and control subjects: a model to study the relevance of stress response in longevity.

'Successful aging', i.e. the ability to attain old age in relatively good health, is believed to be related to the capability to cope with different environmental stresses. Independently of their specific differentiation, all body cells respond to hyperthermia and other stresses with the production of Heat Shock Proteins (HSPs) that play an important role in cell survival. We investigated the heat shock response in B-lymphoid cell lines from 44 centenarians and 23 younger subjects, by studying both HSP70 synthesis and cell survival after hyperthermic treatment. Interestingly, no significant difference could be found between the two age groups as far as HSP70 synthesis was concerned; moreover, cell lines from centenarians appeared to be less prone to heat-induced apoptosis than lines from younger controls. These results, which are in contrast with previous findings showing an age-related decrease of the HSP70 synthesis and of hyperthermic response, corroborate the above mentioned hypothesis that the biological success of centenarians is due to the preservation of the capability to cope with stresses. An A/C polymorphism identified in the promoter region of HSP70-1 gene had been previously shown to affect the probability to attain longevity in females. To investigate if this effect was related to any influence of this polymorphism on HSP70 protein synthesis the correlation between A/C polymorphism and protein synthesis was investigated. We found that cells from AA centenarian females displayed a lower synthesis of HSP70.

Psychological, neuroendocrine and immune measures in non spousal carers of disabled elderly in Italy.

OBJECTIVES: The purpose of this study was to determine whether psychological well being as well as metabolic, neuroendocrine and immune functions were different in non spousal primary caregivers of disabled elderly than in controls. SETTING AND DESIGN: We randomly recruited 38 primary family carers of over 65 year old recipients of health home care services and 37 controls stratified according to sex and age. METHOD: Data were collected on psychological wellbeing (including anxiety, depression and self-perceived quality of life), on neuroendocrine and immune conditions (haemanalysis and metabolic signs, plasma ACTH, cortisol, prolactin, intra-lymphocyte content of beta-endorphins, NK cell activity and number), as well as on the incidence and severity of influenza disease during previous winter. RESULTS: Caregivers showed greater anxiety, although mean scores did not reach pathological levels. Neither depression nor satisfaction on quality of life did differ significantly, nor differences in haemanalisis and metabolic signs were found, apart from leukocyte and lymphocyte number, which was significantly lower in carers. Plasma levels of ACTH, cortisol and prolactin, the intra-lymphocyte content of beta-endorphins as well as the NK cell number and cytotoxicity did not show significant differences. Incidence and severity of influenza episodes was also similar, whereas the duration of influenza disease showed to be significantly longer. CONCLUSIONS: Non spousal caregivers of disabled elderly suffer from only slight alterations of psychological, endocrine and immune parameters, and do not respond very differently to influenza disease. This does not support therefore any generic privilege for them in the allocation of public support or respite services.

Age- and gender-related alterations of the number and clonogenic capacity of circulating CD34+ progenitor cells.

The aim of this study was to evaluate the peripheral representation and the clonogenic capacity of CD34(+) progenitor cells from 130 healthy subjects (80 females and 50 males) ranging in age from 16 to 100 years. We demonstrated that the absolute number of circulating CD34(+) cells progressively and significantly decreased with advancing age, with a 2-fold reduction in subjects aged more than 80 years. The number of granulocyte-macrophagic (CFU-GM), erytroid (BFU-E), and mixed (CFU-GEMM) colonies which developed from the number of CD34(+) purified cells per ml, progressively and significantly decreased with advancing age. The reduction of both CD34(+) cell number and clonogenic capacity during aging was statistically significant in males but not in females. When evaluated on a per cell bases, a significant age-related decrease in the number of CFU-GM colonies was observed in female but not in male subjects. Our study demonstrates the influence of gender on age-related alterations of the number and clonogenic capacity of CD34(+) cells in the peripheral blood. This evidence deserves particular consideration for the future planning of stem cell therapy in age-associated debilitating diseases.

Age-related susceptibility of naive and memory CD4 T cells to apoptosis induced by IL-2 deprivation or PHA addition.

The increased age-associated incidence of infectious and cancer diseases has been related to the alteration of immune functioning found in the elderly (immunosenescence). The reduction of naive T cells, which determine an impaired ability to mount immune responses to new antigens, represents a hallmark of the aging process. The aim of this study was to evaluate the susceptibility to apoptosis of purified naive and memory CD4(+) T cells from peripheral blood of healthy people ranging in age from 20 to 98 years. Two mechanisms of T cell elimination by apoptosis have been evaluated: cytokine deprivation and activation-induced cell death. After Interleukin-2 deprivation, the percentage of naive and memory CD4(+) apoptotic cells significantly increased with donor age concomitantly with a reduction of Bcl-2 expression and an increase of intracellular content of reactive oxygen species. After phytohemagglutinin addition, the percentage of apoptotic cells, the expression of CD95, and the intracellular reactive oxygen species, were not significantly correlated with age both in naive and memory CD4(+) T cells. Our data demonstrate the existence of functional alterations of naive and memory T cell populations during ageing. These alterations are mainly related to the mechanism of the apoptotic event rather than to the type of cell population involved (naive or memory). The alterations of naive and memory T cells may have implications in the age-related susceptibility to diseases.