Italian good practice recommendations on management of persons with Long-COVID.

A significant number of people, following acute SARS-CoV-2 infection, report persistent symptoms or new symptoms that are sustained over time, often affecting different body systems. This condition, commonly referred to as Long-COVID, requires a complex clinical management. In Italy new health facilities specifically dedicated to the diagnosis and care of Long-COVID were implemented. However, the activity of these clinical centers is highly heterogeneous, with wide variation in the type of services provided, specialistic expertise and, ultimately, in the clinical care provided. Recommendations for a uniform management of Long-COVID were therefore needed. Professionals from different disciplines (including general practitioners, specialists in respiratory diseases, infectious diseases, internal medicine, geriatrics, cardiology, neurology, pediatrics, and odontostomatology) were invited to participate, together with a patient representative, in a multidisciplinary Panel appointed to draft Good Practices on clinical management of Long-COVID. The Panel, after extensive literature review, issued recommendations on 3 thematic areas: access to Long-COVID services, clinical evaluation, and organization of the services. The Panel highlighted the importance of providing integrated multidisciplinary care in the management of patients after SARS-CoV-2 infection, and agreed that a multidisciplinary service, one-stop clinic approach could avoid multiple referrals and reduce the number of appointments. In areas where multidisciplinary services are not available, services may be provided through integrated and coordinated primary, community, rehabilitation and mental health services. Management should be adapted according to the patient's needs and should promptly address possible life-threatening complications. The present recommendations could provide guidance and support in standardizing the care provided to Long-COVID patients.

The Burden of Type 1 and Type 2 Diabetes Among Adolescents and Young Adults in 24 Western European Countries, 1990-2019: Results From the Global Burden of Disease Study 2019.

Objectives: As little is known about the burden of type 1 (T1DM) and type 2 diabetes (T2DM) in adolescents in Western Europe (WE), we aimed to explore their epidemiology among 10-24 year-olds. Methods: Estimates were retrieved from the Global Burden of Diseases Study (GBD) 2019. We reported counts, rates per 100,000 population, and percentage changes from 1990 to 2019 for prevalence, incidence and years lived with disability (YLDs) of T1DM and T2DM, and the burden of T2DM in YLDs attributable to high body mass index (HBMI), for 24 WE countries. Results: In 2019, prevalence and disability estimates were higher for T1DM than T2DM among 10-24 years old adolescents in WE. However, T2DM showed a greater increase in prevalence and disability than T1DM in the 30 years observation period in all WE countries. Prevalence increased with age, while only minor differences were observed between sexes. Conclusion: Our findings highlight the substantial burden posed by DM in WE among adolescents. Health system responses are needed for transition services, data collection systems, education, and obesity prevention.

Prevalence and management of dysphagia in nursing home residents in Europe and Israel: the SHELTER Project.

BACKGROUND: Dysphagia is a frequent condition in older nursing home residents (NHRs) which may cause malnutrition and death. Nevertheless, its prevalence is still underestimated and there is still debate about the appropriateness and efficacy of artificial nutrition (AN) in subjects with severe dysphagia. The aim is to assess the prevalence of dysphagia in European and Israeli NHRs, its association with mortality, and the relationship of different nutritional interventions, i.e. texture modified diets and AN-with weight loss and mortality. METHODS: A prospective observational study of 3451 European and Israeli NHRs older than 65 years, participating in the SHELTER study from 2009 to 2011, at baseline and after 12 months. All residents underwent a standardized comprehensive evaluation using the interRAI Long Term Care Facility (LTCF). Cognitive status was assessed using the Cognitive Performance Scale (CPS), functional status using Activities of Daily Living (ADL) Hierarchy scale. Trained staff assessed dysphagia at baseline by clinical observation. Data on weight loss were collected for all participants at baseline and after 12 months. Deaths were registered by NH staff. RESULTS: The prevalence of dysphagia was 30.3%. During the one-year follow-up, the mortality rate in subjects with dysphagia was significantly higher compared with that of non-dysphagic subjects (31.3% vs 17.0%,p = 0,001). The multivariate analysis showed that NHRs with dysphagia had 58.0% higher risk of death within 1 year compared with non-dysphagic subjects (OR 1.58, 95% CI, 1.31-1.91). The majority of NHRs with dysphagia were prescribed texture modified diets (90.6%), while AN was used in less than 10% of subjects. No statistically significant difference was found concerning weight loss and mortality after 12 months following the two different nutritional treatments. CONCLUSIONS: Dysphagia is prevalent among NHRs and it is associated with increased mortality, independent of the nutritional intervention used. Noticeably, after 12 months of nutritional intervention, NHRs treated with AN had similar mortality and weight loss compared to those who were treated with texture modified diets, despite the clinical conditions of patients on AN were more compromised.

Medication Use and Costs Among Older Adults Aged 90 Years and Older in Italy.

Older adults are often affected by multiple chronic conditions and experience geriatric syndromes that may affect the risk/benefit profile of medications. Little is known about the use of such medications in the older population. This article describes medication use and costs in Italian adults aged ≥90 years. Data from the 2019 Pharmaceutical Prescriptions database, concerning data on medications reimbursed by the Italian National Health Service, were analyzed in terms of prevalence and amount of use expressed as defined daily dose/1,000 users (DDD/1,000 users/day), accounting for different age-groups and sex. All individuals aged ≥90 years used at least one medication, with a mean number of 3128 DDD/1,000 users/day corresponding to an annual cost of 683 euros per user. Both use and costs linearly decreased with increasing age, with men accounting for a higher amount of DDD/1,000 users and costs than women across all age-groups. Antihypertensives (1330 DDD/1,000 inhabitants), antiplatelet agents (337 DDD/1,000 inhabitants), medications for peptic ulcer and gastroesophageal reflux (328 DDD/1,000 inhabitants), and lipid-lowering agents (166 DDD/1,000 inhabitants) were the most frequently used medications. We observed a progressive decrease in the usage of the majority of medications with increasing age, with the exception of antibiotics and antipsychotics. Individuals aged ≥90 years used a lower DDD/1,000 users, with an associated decrease in annual costs. The persistent use of preventive medications highlights the potential lack of awareness regarding medication rationalization and guidance for optimizing prescriptions. Our findings highlight the need for further initiatives to improve medications' appropriateness in these older age-groups.

iPhone 12 MagSafe technology and cardiac implantable devices: Assessment of the actual risk.

BACKGROUND: Pacemaker (PM) and implantable cardioverter defibrillators (ICD) are equipped with a magnetic sensor activated by external application of magnets to easily manage some functions of these devices. If activated inadvertently or outside a controlled environment and without the supervision of clinical personnel, this magnetic mode introduces a potential risk. In reality, the possibility of a static magnetic field affecting a PM or ICD is remote. However, the presence of the magnet in the iPhone 12 made the possibility of inadvertently activating the magnetic switch of PM and ICD less remote. OBJECTIVE: This study investigates the effects of magnetic interference of the iPhone 12 on a large set of cardiac implantable devices representative of the current market and proposes adequate rules of conduct. METHODS: We investigated the risk of the magnetic interference of the iPhone 12 and its MagSafe accessories on a comprehensive set of PMs and ICDs, including the subcutaneous ICD. For the first time, the magnetic interference phenomena were correlated with the magnetic field levels measured all around iPhone 12. RESULTS: We discovered that the magnets inside iPhone 12 trigger the magnetic mode in the 12 tested devices up to a distance of 1 cm. CONCLUSIONS: Considering the implications related to the activation of the magnetic switch, to date, it is advisable to follow Apple's indications relating to the safety distance of 15 cm, which is widely compatible with the results obtained from this paper and in line with the indications provided by the implantable cardiac device manufacturers.

Benchmarking European Home Care Models for Older Persons on Societal Costs: The IBenC Study.

This study aims to benchmark mean societal costs per client in different home care models and to describe characteristics of home care models with the lowest societal costs. In this prospective longitudinal study in 6 European countries, 6-month societal costs of resource utilization of 2060 older home care clients were estimated. Three care models were identified and compared based on level of patient-centered care (PCC), availability of specialized professionals (ASP) and level of monitoring of care performance (MCP). Differences in costs between care models were analyzed using linear regression while adjusting for case mix differences. Societal costs incurred in care model 2 (low ASP; high PCC & MCP) were significantly higher than in care model 1 (high ASP, PCC & MCP, mean difference €2230 (10%)) and in care model 3 (low ASP & PCC; high MCP, mean difference €2552 (12%)). Organizations within both models with the lowest societal costs, systematically monitor their care performance. However, organizations within one model arranged their care with a low focus on patient-centered care, and employed mainly generalist care professionals, while organizations in the other model arranged their care delivery with a strong focus on patient-centered care combined with a high availability of specialized care professionals.

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.

Medication Management in Frail Older People: Consensus Principles for Clinical Practice, Research, and Education.

Frailty is a geriatric condition associated with increased vulnerability to adverse drug events and medication-related harm. Existing clinical practice guidelines rarely provide medication management recommendations specific to frail older people. This report presents international consensus principles, generated by the Optimizing Geriatric Pharmacotherapy through Pharmacoepidemiology Network, related to medication management in frail older people. This consensus comprises 7 principles for clinical practice, 6 principles for research, and 4 principles for education. Principles for clinical practice include (1) perform medication reconciliation and maintain an up-to-date medication list; (2) assess and plan based on individual's capacity to self-manage medications; (3) ensure appropriate prescribing and deprescribing; (4) simplify medication regimens when appropriate to reduce unnecessary burden; (5) be alert to the contribution of medications to geriatric syndromes; (6) regularly review medication regimens to align with changing goals of care; and (7) facilitate multidisciplinary communication among patients, caregivers, and healthcare teams. Principles for research include (1) include frail older people in randomized controlled trials; (2) consider frailty status as an effect modifier; (3) ensure collection and reporting of outcome measures important in frailty; (4) assess impact of frailty on pharmacokinetics and pharmacodynamics; (5) encourage frailty research in under-researched settings; and (6) utilize routinely collected linked health data. Principles for education include (1) provide undergraduate and postgraduate education on frailty; (2) minimize low-value care related to medication management; (3) improve health and medication literacy; and (4) incorporate evidence in relation to frailty into clinical practice guidelines. These principles for clinical practice, research and education highlight different considerations for optimizing medication management in frail older people. These principles can be used in conjunction with existing best practice guidelines to help achieve optimal health outcomes for this vulnerable population. Implementation of the principles will require multidisciplinary collaboration between healthcare professionals, researchers, educators, organizational leaders, and policymakers.

Age- and Gender-Related Changes in Physical Function in Community-Dwelling Brazilian Adults Aged 50 to 102 Years.

BACKGROUND AND PURPOSE: Cutoff points for physical function tests are commonly used in clinical practice for the evaluation, monitoring, and treatment of older adults. Previous studies have shown that, while age-related patterns of muscle strength change are similar between ethnic groups, strength values differ significantly independent of age. Whether the same applies to other physical function tests is presently unclear. This study investigated age- and gender-related changes of performance on a battery of physical function tests in Brazilian community dwellers. METHODS: The study followed a cross-sectional design. Participants were community-dwelling adults. Candidates were considered eligible if they were 18 years or older, lived independently, and possessed sufficient physical and cognitive abilities to perform all of the measurements required by the protocol. Physical function tests included isometric handgrip (IHG), 5 times sit-to-stand (5×STS) test, Timed Up and Go, 1-leg stance, and walking speed (WS) at usual and fast pace. RESULTS: Two-thousand eight-hundred and four people were enrolled. Mean age was 68.0 (7.0) years (range 50-102 years), and 2262 (80.7%) were women. Men displayed better IHG and balance, while women showed higher performance on the 5×STS and WS tests. A gender-specific pattern of decline in physical performance was observed. Specifically, women showed a linear age-dependent decline in all tests. In men, only in the IHG, 1-leg stance, and WS test at a fast pace was there a linear decline with age. In both genders, the lowest mean values of physical function tests were higher than the proposed cutoffs for sarcopenia. DISCUSSION AND CONCLUSIONS: Our findings indicate that the performance on different physical function tests decreases with advancing age in Brazilian adults, following a gender-specific pattern. In none of the tests did the lowest mean values reach the cutoffs for sarcopenia. This suggests that region-specific cutoffs might be necessary to identify older people at risk of adverse events.

A comparison of 3 frailty measures and adverse outcomes in the intake home care population: a retrospective cohort study.

BACKGROUND: In Ontario, Canada, nearly all home care patients are assessed with a brief clinical assessment (interRAI Contact Assessment [interRAI CA]) on admission. Our objective was to compare 3 frailty measures that can be operationalized using the interRAI CA. METHODS: We conducted a retrospective cohort study using linked patient-level assessment and administrative data for all Ontario adult (≥ 18 yr) home care patients assessed with the interRAI CA in 2014. We employed multivariable logistic models to compare the Changes in Health, End-stage disease and Signs and Symptoms Scale for the Contact Assessment (CHESS-CA), Assessment Urgency Algorithm (AUA) and the Frailty Index for the Contact Assessment (FI-CA) that was created for this study. Our outcomes of interest were death, hospital admission and emergency department visits within 90 days, and assessor-rated need for comprehensive geriatric assessment (CGA). RESULTS: In 2014, there were 228 679 unique adult home care patients in Ontario assessed with the interRAI CA. Controlling for age, sex and health region, being in a higher frailty level defined by any measure increased the likelihood of experiencing adverse outcomes. Among all assessments, CHESS-CA was best suited for predicting death and hospital admission, and either AUA or FI-CA for predicting perceived need for CGA. Previous emergency department visits were more predictive of future visits than frailty. Model fit was independent of whether the assessment was completed over the phone or in person. INTERPRETATION: Frailty measures from the interRAI CA identified patients at higher risk for death, hospital admission and perceived need for CGA. In jurisdictions where the CHESS-CA and AUA are already built into the electronic home care platform, such as Ontario, patients identified as high risk should be prioritized for proactive referral and care planning, and may benefit from greater involvement of primary care and other health professionals in the circle of care.

Management of hip fracture in the older people: rationale and design of the Italian consensus on the orthogeriatric co-management.

BACKGROUND: Hip fracture (HF) is a burdening health problem in older people. The orthogeriatric approach has been shown to favour functional recovery and reduce mortality, but its implementation in clinical practice cannot rely upon shared management protocols and greatly varies among different healthcare systems. Here, we present the rationale and design of the Italian consensus document on the management of HF in older people. METHODS: A panel of multidisciplinary experts from ten Italian scientific societies involved in the care of HF and including geriatricians, orthopaedics, anaesthesiologists, physiatrists and general practitioners, will join to establish the content validity of a list of statements. A Delphi consensus methodology will be applied to obtain the opinions of the panel and to provide the final recommendations. OBJECTIVES: The document will include indications on the following relevant topics: (1) optimal care path of older subjects with HF; (2) management of comorbidities and pre-operative alteration of physiological parameters; (3) management of selected categories of patients at expected increased risk of adverse outcomes; (4) continuity of care out of hospital; (5) screening and correction of risk factors for HF in older subjects; (6) information and divulgation of shared management strategies. The objective of the consensus will be to inform clinicians, patients, researchers, and health policy makers about the best management strategies for HF in older people and their inherent limitations, thus facilitating communication between stakeholders and promoting the most cost/effective models of care.

Frailty: implications for clinical practice and public health.

Frailty is an emerging global health burden, with major implications for clinical practice and public health. The prevalence of frailty is expected to rise alongside rapid growth in the ageing population. The course of frailty is characterised by a decline in functioning across multiple physiological systems, accompanied by an increased vulnerability to stressors. Having frailty places a person at increased risk of adverse outcomes, including falls, hospitalisation, and mortality. Studies have shown a clear pattern of increased health-care costs and use associated with frailty. All older adults are at risk of developing frailty, although risk levels are substantially higher among those with comorbidities, low socioeconomic position, poor diet, and sedentary lifestyles. Lifestyle and clinical risk factors are potentially modifiable by specific interventions and preventive actions. The concept of frailty is increasingly being used in primary, acute, and specialist care. However, despite efforts over the past three decades, agreement on a standard instrument to identify frailty has not yet been achieved. In this Series paper, we provide an overview of the global impact and burden of frailty, the usefulness of the frailty concept in clinical practice, potential targets for frailty prevention, and directions that need to be explored in the future.

Signs of Inequality? Variations in Providing Home Health Care Across Care Organizations and Across European Countries in the IBenC Study.

Most countries aim to allocate home health care to those in need in a fair and equal way. Equal allocation implies that the amount of home care a person receives would reflect the level of health impairment and the need for resources. It is not clear whether countries succeed in attaining this. Our objective was to explore signs of (un)equal home health care provisioning across care organizations and across European health countries. We used data of the IBenC study collected from 2718 older community care recipients from 33 organizations in 6 Western European countries (www.ibenc.eu). We benchmarked differences of provided and expected formal care time across organizations and countries. Expected formal care hours were estimated by multiplying the overall sample's mean formal hours with recipients' case mix weights from interRAI's resources utilization group profiles. We found substantial variations in provided formal care time among organizations both within and across countries that could not be explained by the case mix differences of recipients. This implied presence of inequality of home care provisioning. These findings may alert professionals and policy makers striving for equal home health care provisioning for dependent older persons.

Predictors of Societal Costs of Older Care-Dependent Adults Living in the Community in 11 European Countries.

BACKGROUND: The objective was to identify predictors of societal costs covering formal and informal care utilization by older home care clients in 11 European countries. METHODS: Societal costs of 1907 older clients receiving home care for 12 months from the Aged in Home care (AdHoc) study were estimated using the InterRAI Minimum Data Set for Home Care's (MDS-HC) resource use items. Predictors (medical, functional, and psychosocial domains) of societal costs were identified by performing univariate and multivariate generalized linear model analyses. RESULTS: Mean societal costs per participant were €36 442, ranging from €14 865 in Denmark to €78 836 in the United Kingdom. In the final multivariate model, country, being married, activities of daily living (ADL) dependency, cognitive impairment, limitations of going out, oral conditions, number of medications, arthritis, and cerebro vascular accident (CVA) were significantly associated with societal costs. CONCLUSIONS: Of the predictors, ADL dependency and limitations of going out may be modifiable. Developing interventions targeted at improving these conditions may create opportunities to curtail societal costs.

The Behavioral and Psychological Symptoms of Dementia in Down Syndrome (BPSD-DS) Scale: Comprehensive Assessment of Psychopathology in Down Syndrome.

People with Down syndrome (DS) are prone to develop Alzheimer's disease (AD). Behavioral and psychological symptoms of dementia (BPSD) are core features, but have not been comprehensively evaluated in DS. In a European multidisciplinary study, the novel Behavioral and Psychological Symptoms of Dementia in Down Syndrome (BPSD-DS) scale was developed to identify frequency and severity of behavioral changes taking account of life-long characteristic behavior. 83 behavioral items in 12 clinically defined sections were evaluated. The central aim was to identify items that change in relation to the dementia status, and thus may differentiate between diagnostic groups. Structured interviews were conducted with informants of persons with DS without dementia (DS, n = 149), with questionable dementia (DS+Q, n = 65), and with diagnosed dementia (DS+AD, n = 67). First exploratory data suggest promising interrater, test-retest, and internal consistency reliability measures. Concerning item relevance, group comparisons revealed pronounced increases in frequency and severity in items of anxiety, sleep disturbances, agitation & stereotypical behavior, aggression, apathy, depressive symptoms, and eating/drinking behavior. The proportion of individuals presenting an increase was highest in DS+AD, intermediate in DS+Q, and lowest in DS. Interestingly, among DS+Q individuals, a substantial proportion already presented increased anxiety, sleep disturbances, apathy, and depressive symptoms, suggesting that these changes occur early in the course of AD. Future efforts should optimize the scale based on current results and clinical experiences, and further study applicability, reliability, and validity. Future application of the scale in daily care may aid caregivers to understand changes, and contribute to timely interventions and adaptation of caregiving.

Polypharmacy in Home Care in Europe: Cross-Sectional Data from the IBenC Study.

BACKGROUND: Home care (HC) patients are characterized by a high level of complexity, which is reflected by the prevalence of multimorbidity and the correlated high drug consumption. This study assesses prevalence and factors associated with polypharmacy in a sample of HC patients in Europe. METHODS: We conducted a cross-sectional analysis on 1873 HC patients from six European countries participating in the Identifying best practices for care-dependent elderly by Benchmarking Costs and outcomes of community care (IBenC) project. Data were collected using the interResident Assessment Instrument (interRAI) instrument for HC. Polypharmacy status was categorized into three groups: non-polypharmacy (0-4 drugs), polypharmacy (5-9 drugs), and excessive polypharmacy (≥ 10 drugs). Multinomial logistic regressions were used to identify variables associated with polypharmacy and excessive polypharmacy. RESULTS: Polypharmacy was observed in 730 (39.0%) HC patients and excessive polypharmacy in 433 (23.1%). As compared with non-polypharmacy, excessive polypharmacy was directly associated with chronic disease but also with female sex (odds ratio [OR] 1.58; 95% confidence interval [CI] 1.17-2.13), pain (OR 1.51; 95% CI 1.15-1.98), dyspnea (OR 1.37; 95% CI 1.01-1.89), and falls (OR 1.55; 95% CI 1.01-2.40). An inverse association with excessive polypharmacy was shown for age (OR 0.69; 95% CI 0.56-0.83). CONCLUSIONS: Polypharmacy and excessive polypharmacy are common among HC patients in Europe. Factors associated with polypharmacy status include not only co-morbidity but also specific symptoms and age.

Educational strategies to train health care professionals across the education continuum on the process of frailty prevention and frailty management: a systematic review.

BACKGROUND: In addition to the normal process of ageing, frailty, defined as a geriatric syndrome, is becoming more prevalent. Around 10% of people over 65 years and 25-50% of those aged over 85 years are frail. Frail elderly are more vulnerable to external stressors and have an increased risk of adverse health outcomes. To tackle these challenges, European Union (EU) member states need to develop a health work force capable of the right skills mix. A goal-centred education and training of professionals is crucial for effective and efficient health care delivery for Europe's greying population. AIMS: The aim of this study was to systematically collect, review and critically appraise studies carried out to investigate the efficacy and effectiveness of comprehensive educational programmes for health professionals related to frailty prevention and/or frailty management. METHODS: A systematic review was carried out searching the databases PubMed, CINAHL, Cochrane CENTRAL, Medline, Up to date and Embase. Additionally, a manual search of the reference lists and searches via Google Scholar and greylit.org was done. RESULTS: No relevant publications addressing the evidence and sustainability of educational/training programmes for frailty prevention and/or frailty management were identified. DISCUSSION: The result of an empty review is surprising because several educational programmes in different countries are currently run. CONCLUSIONS: A significant knowledge gap exists in the scientific literature regarding education and training of health care workers regarding prevention and management of frailty. Further research is needed to identify effective educational strategies for health professionals to prevent and manage frailty.