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.

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.

Clinical instability as a predictor of negative outcomes among elderly patients admitted to a rehabilitation ward.

OBJECTIVES: To assess the impact of clinical instability (CI) and delirium on admission to a rehabilitation unit on clinical and functional outcomes (death, transfer to acute care, poor functional recovery) at discharge, in a population of elderly patients. DESIGN: Observational study. SETTING: Rehabilitation and Aged Care Unit (RACU). PARTICIPANTS: Participants were 583 consecutively and firstly admitted elderly patients. MEASUREMENTS: On admission, all patients underwent a comprehensive geriatric assessment including sociodemographics, cognitive and depressive symptoms, nutritional status, physical health, and functional status. CI was recorded for all patients on admission, assessing 5 vital signs (temperature, heart rate, systolic blood pressure, respiratory rate, and oxygen saturation). Delirium was assessed daily with the Confusion Assessment Method. RESULTS: Patients were on average old (mean age: 77.8 +/- 9.8), predominantly female (68.6%), with mild cognitive deterioration (MMSE: 22.1 +/- 6.3) and depressive symptoms (GDS: 5.9 +/- 3.5). They had moderate comorbidity (means CIRS: 3.1 +/- 1.9), and functional impairment both before (Barthel Index pre-admission: 84.5 +/- 19.2; IADL: 3.3 +/- 3.0) and on admission (Barthel Index: 55.8 +/- 27.5). On admission, 136 (23.3%) patients were classified as clinically unstable: 76 (13%) had either CI or delirium, and 60 (10.3%) had CI associated to delirium. At discharge, 26 patients were transferred to acute care hospitals, and 14 died. Transfer to acute care occurred in more than 10% of patients with almost one altered condition (CI or delirium), and in one fifth of patients with the association of CI and delirium. In-RACU death was observed only in this latter group. Functional recovery at discharge was significantly higher in stable patients than in patients with CI and/or delirium. CONCLUSIONS: CI and delirium are useful prognostic markers of adverse clinical and functional outcomes in a population of elderly subjects admitted to a rehabilitative unit.

The importance of Alzheimer disease assessment scale-cognitive part in predicting progress for amnestic mild cognitive impairment to Alzheimer disease.

The aim of this study was to verify the usefulness of Alzheimer Disease Assessment Scale-cognitive subscale (ADAS-Cog), in screening participants at risk of developing Alzheimer disease (AD) among populations with amnestic mild cognitive impairment(aMCI). 98 outpatients with aMCI were recruited. Participants were revaluated after 1 year: 44 (44.9%) were progressed to AD (progressors), while 54 (55.1%) did not convert (nonprogressors MCI). At baseline, cognitive performances were more impaired in progressors assessed by MMSE and by a neuropsychological battery. When tested with the ADAS-Cog subscale, the 2 groups of participants at baseline, progressors, and nonprogressors MCI, were significantly different regarding total score, memory, and nonmemory subitems. Considering a cutoff of 9.5 total score, adjusted for education, ADAS-Cog subscale showed a good performance (area under the curve = 0.67; sensitivity = 0.62%; specificity = 0.73%) in predicting conversion from aMCI to AD. Progressors aMCI were characterized at baseline by a greater cognitive impairment. ADAS-Cog subscale is a useful and brief cognitive assessment tool to screen aMCI participants converting to AD within 1 year.

Predictors of institutionalization in demented patients discharged from a rehabilitation unit.

BACKGROUND: The decision to place a patient with dementia in long-term care is complex and based on the patient's and the caregiver's characteristics, and on the sociocultural context. Most studies assessing predictors of nursing home placement focused primarily on the characteristics of either the patient, such as dementia severity and difficult behaviors, or the caregiver, such as subjective burden and health status. However, only a few studies comprehensively investigated how both a caregiver's and a patient's characteristics influence nursing home placement. OBJECTIVE: To identify the patient's and the caregiver's characteristics that influence discharge to a nursing home in demented patients consecutively admitted to an intermediate care setting. METHODS: Observational study of 214 patients with dementia consecutively admitted to a Rehabilitation Unit for Dementia in Northern Italy (length of stay 35.1 +/- 14.9 days). The main evaluated outcome was the final destination (home vs nursing home). RESULTS: In a multivariate logistic regression analysis, adjusted for age, gender, cognitive status, and behavioral disturbances, 4 predictors were associated with nursing home placement: living alone (OR 8.79, 95% CI 2.33-33.16; P = .001), degree of dementia severity (CDR, OR 1.69, 95% CI 1.02-2.83; P = .04), compromised functional status (Barthel index admission, OR 3.15, 95% CI 1.05-9.48; P = .04), and caregiver's burden (CBI, OR 2.89, 95% CI 1.15-7.29; P = .02). CONCLUSIONS: Data suggest that living alone, patient's functional impairment, severity of dementia, and caregiver's burden were independent predictors of institutionalization. The interaction between a patient's and a caregiver's characteristics has an important effect on the rate of nursing home placement in demented patients.

Predictive role of single diseases and their combination on recovery of balance and gait in disabled elderly patients.

OBJECTIVES: In the elderly population, chronic diseases are common determinants of mobility limitations and comorbidity consistently shows a strong association with functional status. This study was designed to evaluate the role of single chronic diseases and of their combination on functional recovery after rehabilitative treatment in disabled elderly patients. DESIGN: With respect to the difference in magnitude of their disabling effect, diseases were classified into 2 groups: "more disabling" diseases (COPD, heart failure, peripheral artery diseases, diabetes, and not life-threatening cancer) and "less disabling" diseases (anemia, kidney, gastrointestinal, and liver diseases). SETTING: 35-bed Geriatric Evaluation and Rehabilitation Unit. PARTICIPANTS: We studied 710 patients (age 77.8 +/- 7.4 years, 76.2% females), consecutively admitted for stroke, Parkinson's disease, and osteoarthritis. MEASUREMENTS: A multidimensional evaluation for mobility (Tinetti-score), cognitive status (MMSE), and somatic health (Greenfield's Individual Disease Severity Index-IDS, Burden of diseases-BoD) was performed. Functional recovery was decided based on the Delta-Tinetti, which is the difference of the values between admission and discharge. RESULTS: We tested, in a multivariate regression model, the predictive role of single chronic conditions and of their combinations on functional recovery, after having adjusted for which diseases are direct causes of disability (stroke, Parkinson's disease, and osteoarthritis) and other potential predictors (age, sex, cognitive function, depressive symptoms, albumin, and c-reactive protein). A negative prediction of functional recovery was expressed by the "more disabling" diseases group. The determinants of poor recovery were characterized by the combination of "more disabling diseases" rather than single condition effects, independently by age, cognitive, and functional status on admission. CONCLUSION: Our study adds a new perspective about the role of COPD, heart failure, peripheral artery diseases, diabetes and not life-threatening cancer on functional recovery, emphasizing their combined impact in elderly people.

Diagnosis of chronic pain caused by osteoarthritis and prescription of analgesics in patients with cognitive impairment.

OBJECTIVE: Evaluation of the ability to detect symptoms of osteoarthritis and prescription of analgesics in older adults with different degrees of cognitive impairment. SETTING AND PATIENTS: Patients consecutively admitted to a Geriatric Evaluation and Rehabilitation Unit (GERU) for disability due to orthopedic, neurological, or cardiopulmonary diseases, after a surgical intervention, or for behavioral disturbances of dementia. Subjects with a recent orthopedic intervention were excluded. Eight hundred eighty-eight patients were analyzed (mean age 78.4 +/- 7.2 years, 69.5% female) and divided into 4 groups according to cognitive impairment: severe (Mini-Mental State Examination, MMSE 0-12), moderate (MMSE 13-18), mild (MMSE 19-24), or absent (MMSE 25-30). METHODS: Patients underwent a geriatric multidimensional assessment; the diagnosis of musculoskeletal pain was based on patients' direct report, objective signs (inflammatory signs around the joints), and "pain behaviors" (reductions in activity, social withdrawal, self-protective maneuvers, increased alterations in facial expressions or body postures, observable displays of distress). Analgesic drugs were registered on discharge in subjects with symptomatic osteoarthritis. RESULTS: Of the patients admitted to GERU, 16.8% (n = 149) had osteoarthritis; this percentage is different according to cognitive impairment (MMSE 0-12: 1%, MMSE 13-18: 8%, MMSE 19-24: 17.4%, MMSE 24-30: 34.1%, P < .001). If patients admitted for osteoarthritis are excluded, the new diagnoses of pain due to osteoarthritis are 306 (41.4%), without differences between cognitive status groups. On discharge, analgesic drugs are prescribed to 28.8% of patients with symptomatic arthritis (n = 131); the percentage is lower in patients with severe cognitive impairment in comparison with subjects with better cognitive functions. CONCLUSION: There is a poor attention to chronic pain due to osteoarthritis in community-dwelling elders with cognitive impairment. In a rehabilitative setting, an accurate evaluation of objective signs allows the diagnosis of symptomatic osteoarthritis. However, the link between the diagnosis and the treatment is not direct, since the prescription of analgesics is lower in patients with a more severe cognitive impairment.

Guidelines for the treatment of Alzheimer's disease from the Italian Association of Psychogeriatrics.

A committee of experts from the Italian Association of Psychogeriatrics compiled the following report, which was then approved by a Steering Committee (comprising 20 specialists in neurology, psychiatry or geriatrics) from the Association and by two Alzheimer associations representing patients and families: the Italian Association for Alzheimer's Disease and the Italian Federation for Alzheimer's Disease. The report is based on a comprehensive review of the scientific literature on the treatment of Alzheimer's disease, discusses methodological aspects of dementia management, and details the limitations of current therapies. These guidelines are, in general, consistent with the principles of evidence-based medicine; however, for some controversial or poorly investigated issues, the guidelines integrate scientific evidence with experience and opinions from experts working in the clinical setting. In particular, the clinical experience of experts has been used to define recommendations for starting and interrupting pharmacotherapy, and to critically review evidence about the efficacy of non-pharmacological interventions. The principal pharmacotherapeutic interventions covered in the guidelines are acetylcholinesterase inhibitors (donepezil, galantamine, rivastigmine, and tacrine) and memantine. The main non-pharmacological interventions reviewed are memory training, reality orientation therapy, and combined non-pharmacological interventions. Other issues covered are opportunities for Alzheimer's disease prevention, various modalities of care, and the treatment of comorbidities.