The Marigliano-Cacciafesta polypathology scale (MCPS): a tool for predicting the risk of developing disability.

The purpose of the work was to verify whether our MCPS can be a tool for predicting the risk of developing disabilities. We considered 45 elderly subjects divided into three groups of 15 subjects each. Group 1 consisted of cases with a "moderate-severe" degree of polypathology, with no associated condition of disability evaluated by means of the activities of daily living (ADL). Group 2 contained cases with a "moderate" degree of polypathology (with no associated condition of ADL disability). The Group 3 was the control group with a "mild" degree of polypathology (with no disability associated with ADL). All subjects were re-evaluated after 6 and 12 months. Both Groups 1 and 2 of cases over time developed greater disabilities, compared to the control Group 3; in particular, the subjects with "moderate-severe" polypathology were more disabled after 12 months.

The Marigliano-Cacciafesta polypathological scale: a tool for assessing fragility.

The aim of our studies was to establish a standard method of assessment that allows an early identification of frailty in the elderly, i.e., to predict who are at risk of developing disabilities, in order to be able to intervene with preventive global and individualized measures. A new multidimensional scale called Marigliano-Cacciafesta polypathological scale (MCPS) was used on 180 elderly people, together with the Barthel index (BI), the global evaluation functional index (GEFI), the geriatric depression scale (GDS), the mini mental state examination (MMSE), the mini nutritional assessment (MNA), and the Tinetti test. A strongly significant statistical correlation was found between the MCPS and the nutritional state, mood level, motor functionality, level of disability and global functionality. As the fragile patients are at a risk to develop disabilities, we think that our scale can be a significant contribution to the multidimensional geriatric assessment (MGA), aimed at identifying and quantifying the parameter of fragility of each patient, an information which should be known, if we intend to introduce preventive measures.

Cognitive function by brain event-related potentials (ERP) in elderly with borderline isolated systolic hypertension (BISH).

Several studies have shown a relationship between BISH and cerebrovascular events, but no studies have investigated a relationship with cognitive function. The aim was to assess the cognitive function in the elderly with recent BISH. According to WHO Guidelines (1999), we selected 10 elderly normotensives, 10 elderly with recently diagnosed (<2 years) BISH, and 10 elderly with recently diagnosed (<2 years) isolated systolic hypertension (ISH). They were submitted to 24-hr ambulatory blood pressure (BP) monitoring (ABPM) and to cognitive assessment by mini mental state examination (MMSE) and the recording of brain ERP, of type N2 and P300. The elderly with BISH, compared to normotensives, showed N2 wave latency values significantly higher, but similar P300 potential latency values and MMSE scores. The elderly with ISH showed N2 and P300 latency significantly higher than the normotensives. The gradual increase of the ERP latency values of the BISH and ISH elderly, in comparison to the normotensives, seems to indicate a gradual alteration of the cognitive processes related to the increase of BP.

Sleep quality of centenarians: cognitive and survival implications.

Sleep is an active nervous process, which is structured in phases characterized by subsequent cycles of various psycho-physiological phenomena. It performs vital, yet mysterious functions and is in all likelihood involved in many processes, including cognitive processes. In old age the internal structure of sleep changes, but these physiological variations allow, in healthy subjects, a satisfactory quantity and quality of sleep. Until now there have been no literature reports of studies regarding sleep quality in extreme old age. Our work describes the investigation of the quality of sleep in a sample of 180 centenarians selected from the registered residents of Rome. We have studied sleep disorders, related pathologies and pharmacological treatments. The results of the study show good sleep quality for 57.4% of the sample group; 35.2% complain of medium intensity problems, significantly related to angina pectoris and to chronic obstructive bronchopneumopathy. Only 7.4% of the subjects showed severe problems, significantly related with cognitive deficiency and lower survival rate. The results of our study confirm, in centenarians as in the elderly, the existence of a positive correlation between sleep quality, survival and successful aging.

Pulsatile versus steady-state component of blood pressure in elderly females: an independent risk factor for cardiovascular disease?

OBJECTIVE: To evaluate whether the pulsatile component of blood pressure can be a risk factor independent of the steady component in elderly females. DESIGN: Fifty-two elderly hypertensive female patients were compared with 32 normotensive control subjects of the same age. According to the results of that first study, a cohort of 126 elderly females was studied over a 3-year period to evaluate whether the pulsatile and steady-state components of blood pressure correlated with the same parameters and could predict the occurrence of cardiovascular events. RESULTS: In the first study the hypertensive patients with elevated pulse pressure had significantly higher triglycerides level and lower urinary sodium excretion than the hypertensive patients with lower pulse pressure and than the control subjects of the same age. The incidence of cardiovascular events over a 3-year period was significantly higher in the elderly hypertensive females with increased pulse pressure. In the cohort of 126 females mean arterial pressure (MAP) and pulse pressure did not show the same degree of correlation with the biological parameters tested (plasma triglycerides: MAP r = 0.162, P < 0.05; pulse pressure r = 0.314, P < 0.0005; urinary sodium excretion: MAP r = -0.365, P < 0.0001; pulse pressure r = -0.257, P < 0.002). Furthermore, for the same MAP level, patients with cardiovascular accidents in a 3-year period had significantly higher pulse pressure values. Pulse pressure (and not MAP) was a strong predictor of cardiovascular accidents. CONCLUSIONS: In elderly hypertensive females the pulsatile and the steady-state components of blood pressure did not correlate with the same biological parameters. Furthermore, the pulsatile component, when explored by pulse pressure, seemed to be a strong independent cardiovascular risk factor.

White-coat hypertension and cardiac organ damage in elderly subjects.

PURPOSE: The aim of this study was comparing the cardiac mass in elderly normotensive subjects and elderly white-coat hypertensive patients by examining in perspective, in consecutive patients, office blood pressure (BP), ambulatory BP, and echocardiographically determined left ventricular mass. PATIENTS AND METHODS: We studied 42 elderly patients attending a hypertension unit: of these, 22 (mean age 68.7 +/- 3.2 years) had persistent > 90 mm Hg office diastolic blood pressure (DBP), > 140 mm Hg systolic blood pressure (SBP) and < 142/90 mm Hg daytime ambulatory BP (white-coat positives); the remaining 20 (mean age 67.4 +/- 2.2 years) had < 90 mm Hg office DBP, < 140 mm Hg SBP and < 142/90 mm Hg daytime ambulatory BP (normotensives). White coat-patients (n = 22) were selected from a series of 75 consecutive newly diagnosed and never treated patients with mild hypertension (casual DBP constantly between 90 mm Hg and 105 mm Hg). RESULTS: Neither left ventricular mass index (89.9 +/- 23.1 vs 91.8 +/-25.4 P = NS and +/- 25.4 P = NS) and left ventricular mass/height, (115.4 +/- 17.1 vs 119.6 +/- 18.3 P = NS), nor relative wall thickness (0.31 +/- 0.44 vs 0.33 +/- 0.05 P = NS) were significantly higher in white-coat hypertensives as against normotensives. Neither did we find a relevant difference between left atrial diameters in the above considered groups (3.28 +/- 0.41 vs 3.32 +/- 0.37). In fact 81.8% of white-coat hypertensives had left ventricular normal geometry; whilst 13.6% only had concentric remodeling. Age and sex were associated with left ventricular mass index, left ventricular mass/height and relative wall thickness. Multiple regression analysis revealed that it is ambulatory, not office BP that carries independent information about relative wall thickness and left ventricular mass indices. CONCLUSIONS: Since elderly white-coat hypertensive subjects did not display a greater cardiac involvement than age-matched normotensives, they should be treated as such.

A case report on the effect of training and low caloric diet in hypertension, obesity and hyperinsulinemia.

In an obese hypertensive woman affected by angina-like chest pain, a physical training program and a low caloric diet resulted in a notable improvement of the anthropometric indexes, hyperinsulinemia, myocardial perfusion and left ventricular mass.

Ambulatory blood pressure and echocardiographic left ventricular dimensions in elderly hypertensive subjects.

In a consecutive series of 62 hypertensive elderly subjects, the authors studied the relation of blood pressure circadian variations with echocardiographic parameters of left ventricular (LV) hypertrophy. All the subjects were submitted to an ambulatory blood pressure monitoring (ABPM) and to B- and M-mode echocardiography. In the elderly hypertensive group, LV mass index (LVMI) was more strongly related to twenty-four-hour, daytime and nighttime systolic ambulatory blood pressure (r = 0.52, r = 0.37, r = 0.51) than diastolic ambulatory blood pressures were (r = 0.32, r = 0.18, r = 0.33). Casual systolic and diastolic blood pressure (CBP) was found more weakly related to LVMI than ambulatory blood pressures were (r = 0.35, r = 0.26). Elderly hypertensive subjects were divided into two subgroups in relation to the presence (group 1) or absence (group 2) of blood pressure nocturnal decline. No differences were found between these two subgroups in regard to: casual blood pressure values, ambulatory blood pressures in the diurnal period, sex, body surface area, height, weight, and age. LVMIs were computed in all three groups and showed the following results: 89.32 +/- 19.76 in elderly normotensives, 91.21 +/- 31.32 in group 1, and 99.80 +/- 18.21 in group 2. Echocardiographic parameters of LV dimensions and LVMIs were different in group 1 and 2. An inverse correlation, statistically significant, was observed between LVMIs and the nocturnal blood pressure reduction (systolic: r = -0.36, P < 0.05; diastolic: r = -0.29, P < 0.05). These results suggest an association between a smaller LV mass and nocturnal blood pressure decline in elderly hypertensive patients.

Functional status and well-being of centenarians.

Data regarding a sample of 109 centenarians are presented, living in the region of central Italy. Physical and psychosocial variables were analyzed by a questionnaire based on a multidimensional conceptualization of health. Objective and laboratory data were collected and functional capacity was complemented by clinical diagnoses and judgements as well as by self-reported health problems and functional limitations. The results reveal that people can reach their maximum life span while maintaining good levels of functional capacity in spite of the chronological age. One major aspect of functional status in upper ranges of human life span is the everyday competence in the activities of daily living (ADL). In this regard, 26.6% of centenarians are classified as having no ADL-dependency (level A: 34.6% of males and 24.0% of females); the most frequent type of dependency was in bathing (65.1%; 46.2% of males, 71.1% of females) and in continence (45.9%; 50% of males, 44.6% of females). The Mini Mental State Examination (MMSE) showed a mean score of 19.86 +/- 5.93 (21.04 +/- 5.33 of males; 19.49 +/- 6.10 of females). The Geriatric Depression Scale (GDS) mean score was 8.22 +/- 4.89 (7.60 +/- 5.05 of males, 8.40 +/- 4.87 of females).

Autopsy study of very old hospitalized patients.

All autopsies (n = 63) performed over the period from January 1, 1989 to December 31, 1990 on patients older than 85 years who died at the Policlinico Umberto I of Rome were reviewed retrospectively. The purpose of the study was to determine the autopsy rate, to ascertain accordance between clinical and pathological diagnoses and to clarify problems in diagnosis and complications of geriatric management in our University Hospital. The autopsy rate was 12.1%. The diagnostic error was particularly high for pulmonary embolism. In 26% of cases both the causes of death and the major clinical diagnoses were confirmed.

[Valley/peak ratio and pressure changes during treatment with fosinopril in hypertensive elderly patients]. / Rapporto valle/picco e variabilità pressoria durante terapia con fosinopril in pazienti anziani ipertesi.

Antihypertensive drug therapy uniformity of efficacy was evaluated in a group of elderly hypertensive subjects with trough-to-peak ratio, after a period of antihypertensive drug therapy with ACE-inhibitor fosinopril. An ambulatory blood pressure monitoring (ABPM) with evaluation of blood pressure variability assessed by standard deviation (S.D.) and coefficient of variation (C.V.) were evaluated in each subjects. Our preliminary data showed that the treatment with fosinopril had satisfactory uniformity of efficacy during all the 24-hour period, with both full dose (20 mg) and reduced dose (10 mg); little influence on blood pressure variability was determined by antihypertensive treatment.

[Arterial hypertension in very old people. Problems of treatment]. / Ipertensione arteriosa nei molto anziani. Problemi di trattamento.

Several epidemiological tests showed that, in the very old, low blood pressure was associated with higher mortality and hypertension with a longer life. But more recent studies, some from our school, and the data from Framingham have clarified that the higher mortality in the very old with low blood pressure is to be attributed to pre-existing pathologies which caused the low blood pressure in the first place. Though specific intervention trials on the very old are not available, the analyses of the results of antihypertensive therapy in the sub-groups of the very old in some trials carried-out with elderly hypertensives suggest the use of pharmacological treatment also in the very old (> 80 yrs), at least for isolated systolic hypertension. The therapy must be based on a careful choice of drugs and carried-out with particular caution to avoid disability from hypertension as well as to avoid side effects which worsen the quality of life of your very old patients.

[Nutritional deficiency and Alzheimer's disease: how to identify and prevent]. / Deficit nutrizionale e demenza di Alzheimer: come individuarlo e prevenirlo.

Weight loss is a very common problem for patients with Alzheimer's Disease (AD), whether they live at home or in long-term care facilities. At any rate it depends on an imbalance between energy expenditure and intake. Though in the initial phases of the illness, the weight loss might be caused by socio-environmental and psychological factors and reduced autonomy, in the following stages it depends on Adversive Feeding Behaviours (AFBs). The AFBs invariably lead to protein, fat and sugar deficits as well as a vitamin deficit which presents a positive correlation with the cognitive performance level and negatively affects the course of the disease. Thus it is important to identify AFBs (Blandford Scale) as soon as possible, especially when they can be treated. Furthermore it is very important to recognise weight loss immediately and identify a possible malnutrition state, using investigative methods which allow for follow-up monitoring (Mini Nutritional Assessment). Pharmacological therapy of cognitive deficit and AFBs together with possible contemporary conditions (depression) and intervention on the nutrition, will be useful to avoid a deficiency state and the consequent negative repercussion on the disease.

[Cardiovascular risk factors and diseases in centenarians]. / Fattori di rischio e patologie cardiovascolari nei centenari.

Aging is considered a product of an interaction between genetic, environmental and lifestyle factors. Are centenarians, who have almost arrived at the maximum life-span (120 yrs), free of cardiovascular disease or do they have an increased resistance? How many cardiovascular risk factors are present? We have studied a group of 148 centenarians selected from registered residents of Rome (average age 101.8 +/- 1.9; range 100-108). Their health was assessed through direct 1.5 hour interviews, conducted by physicians with geriatric training at the patient's residence, which includes geriatric assessment scales' submission. The prevalence of cardiovascular disease of our centenarians is 16.7%, represented by heart failure (8%), myocardial infarction (4.7%) and angina pectoris (4%). Among the cardiovascular risk factors, hypertension (31.1%) and hypercholesterolemia are the most frequent, while diabetes is not present. These data, compared with younger samples, point out a lower percentage of cardiovascular disease and risk factors. Moreover centenarians have always conducted a healthy lifestyle (Mediterranean diet, smoking abstention, physical activity, low levels of anxiety and depression). Finally, having identified the golden mean which allows us to carry out a programmed intervention for the prevention of cardiovascular risk factors and diseases, we will be able to increase longevity, allowing a larger number of subjects to reach the maximum human life-span.

[Rehabilitation in Alzheimer's dementia]. / Riabilitazione nella demenza di Alzheimer.

Alzheimer's disease is a neurodegenerative disease that causes a progressive decline of cognitive and behavioural functions. The simultaneous presence of these disorders requires a treatment not only for cognitive decline, but also for behavioural symptoms, depression and caregiver's stress. Research has made many efforts to develop a wide range of treatments, different from current pharmacological therapy, which is not resolutive, owing to the absence of an exact etiopathogenetic mechanism. Since new drugs have not been shown to be really effective in slowing cognitive impairment, various forms of rehabilitative interventions have been proposed in order to treat Alzheimer's disease. Their efficacy in the improvement of cognitive functions is still not completely clear. Surely, interesting results have been obtained from studies about Reality Orientation Therapy, Occupational Therapy and Memory Training. Music therapy might provide a new form of rehabilitative intervention, especially acting on the reducing of behavioural symptoms. These alternative forms of non pharmacological treatment may have a positive effect on caregiver. The heavy emotional burden of seeing a loved one becoming confused and isolated and of having to accept new responsibilities, may be reduced by rehabilitative supports, complementary to the pharmacological therapy. Caregiver stress could be reduced in two ways: by promoting the hope that something is being done for the patient and providing free time for himself.

New frontiers of cognitive rehabilitation in geriatric age: the Mozart Effect (ME).

The ME was described for the first time in 1993. Subsequently other studies with similar designs were performed. The present study, therefore, proposes: (i) to verify the existence of the benefits of exposure to music in elderly subjects with mild cognitive impairment (MCI), (ii) to explore whether it is possible to find any lasting improvement after training, conducted for a long period of time, with such musical pieces, in the measurable cognitive performances. The study we conducted showed that the ME is present in geriatric patients with MCI; the influence on spatial-temporal abilities remains constant in time if the stimulation is maintained. The continuation of our study will consist of increasing the number of individuals examined and in having them listen to music during the study of ECG rhythms and during the acquisition of cerebral functional magnetic resonance imaging (fMRI), and, at the same time, testing them by neuropsychometric methods.