Mini-Mental State Examination: new normative values on subjects in Southern Italy.

OBJECTIVE: The aims of the present study were: (a) to obtain new normative data of the Italian version of the Mini-Mental Examination State (MMSE) (Measso et al. in Dev Neuropsychol 9:77-85, 1993) by administering the tool to a sample of normal Italian individuals more representative of the current Italian population; (b) to compare the sensitivity of this tool in detecting patients suffering from Alzheimer's disease (AD according to NIA-AA), as compared to the those reported in previous normative Italian studies. METHODS: MMSE was administered to 314 normal subjects recruited among individuals (and/or their relatives) attending the Offices of General Practitioners (GP) or Memory Clinics in Campania (Italy) by convenience sampling. A group of 47 patients with AD were included into the study. The effect of demographic variables on the raw MMSE scores of normal subjects was checked by multiple linear regression assuming MMSE scores as dependent variable and age, gender and education as the independent one(s). Therefore, a simultaneous regression model was constructed to correct the raw scores according the sensitive variables. Correction grid and equivalent scores were devised to classify subject's performance. RESULTS: The mean raw MMSE score was 27.78 (SD = 1.80) (range 22-30/30). There was no significant difference between scores achieved by men or women (p = 0.688). Multiple linear regression analysis showed a significant effect of age and years of school attendance on the MMSE raw score, whereas gender did not show any significant effect. The cutoff score, distinguishing between pathological and normal performances, was fixed at the fifth centile corresponding to 24.9/30, higher than the current score of 23.8/30. The new cutoff value was able to identify 44/47 patients with AD, in contrast to 38/47 subjects detected by currently used norms. CONCLUSIONS: (1) A more updated and representative population sample; (2) a new cutoff threshold able to distinguish between normal and pathological performances; (3) a correction grid that reduces the risk of false-positive and false-negative values due to the influence of the main demographic factors; (4) greater sensitivity, compared to previous Italian normative studies in identifying people with dementia.

The Italian version of the quick mild cognitive impairment (Qmci-I) screen: normative study on 307 healthy subjects.

OBJECTIVE: To devise an Italian version of the quick mild cognitive impairment screen (Qmci) and to obtain normative data. METHODS: An Italian version of the Qmci screen (Qmci-I) was administered to 307 subjects free from cognitive impairment. The normative sample was divided into three age levels (50-59; 60-69 and 70-80 years) and four education levels (3-5; 6-8; 9-13; >13 years of school attendance). Multiple regression analyses were used to evaluate the effect of age, sex and schooling on Qmci-I scores (overall and by domains) and to calculate cut-off values, with reference to the confidence interval on the fifth centile. RESULTS: The mean Qmci-I score was 64/100 (SD = 11). The age variable showed a significant negative effect on the overall Qmci-I score, with older people performing worse than younger ones. Conversely, education was associated with higher scores. Significant effects of age and education affected logical memory alone. For the other domains, the following effects were found: (1) higher age associated with lower scores on delayed recall; (2) higher education levels associated with higher scores on immediate recall, clock drawing and word fluency. The adjusted cut-off score for the Qmci-I screen in this sample was 49.4. Qmci-I scores were weakly correlated with those of MMSE (rho = 0.20). CONCLUSIONS: The Qmci-I is a rapid and multi-domain short cognitive screening instrument useful for evaluating cognitive functions. However, like other screening tools, it is significantly influenced by age and education, requiring normative data and correction of values when used in the clinical practice.

Simultaneous resting-state FDG-PET/fMRI in Alzheimer Disease: Relationship between glucose metabolism and intrinsic activity.

Simultaneously evaluating resting-state brain glucose metabolism and intrinsic functional activity has potential to impact the clinical neurosciences of Alzheimer Disease (AD). Indeed, integrating such combined information obtained in the same physiological setting may clarify how impairments in neuroenergetic and neuronal function interact and contribute to the mechanisms underlying AD. The present study used this multimodality approach to investigate, by means of a hybrid PET/MR scanner, the coupling between glucose consumption and intrinsic functional activity in 23 patients with AD-related cognitive impairment ranging from amnestic mild cognitive impairment (MCI) to mild-moderate AD (aMCI/AD), in comparison with a group of 23 healthy elderly controls. Between-group (Controls > Patients) comparisons were conducted on data from both imaging modalities using voxelwise 2-sample t-tests, corrected for partial-volume effects, head motion, age, gender and multiple tests. FDG-PET/fMRI relationships were assessed within and across subjects using Spearman partial correlations for three different resting-state fMRI (rs-fMRI) metrics sensitive to AD: fractional amplitude of low frequency fluctuations (fALFF), regional homogeneity (ReHo) and group independent component analysis with dual regression (gICA-DR). FDG and rs-fMRI metrics distinguished aMCI/AD from controls according to spatial patterns analogous to those found in stand-alone studies. Within-subject correlations were comparable across the three rs-fMRI metrics. Correlations were overall high in healthy controls (ρ = 0.80 ±â€¯0.04), but showed a significant 17% reduction (p < 0.05) in aMCI/AD patients (ρ = 0.67 ±â€¯0.05). Positive across-subject correlations were overall moderate (ρ = 0.33 ±â€¯0.07) and consistent across rs-fMRI metrics. These were confined around AD-target posterior regions for metrics of functional connectivity (ReHo and gICA-DR). In contrast, FDG/fALFF correlations were distributed in the frontal gyrus, thalami and caudate nuclei. Taken together, these results support the presence of bioenergetic coupling between glucose utilization and rapid transmission of neural information in healthy ageing, which is substantially reduced in aMCI/AD, suggesting that abnormal glucose utilization is in some way linked to communication breakdown among brain regions impacted by the underlying pathological process.

Depressive symptoms in patients admitted to a semi-intensive stroke unit.

Aim of this study was to evaluate depressive symptoms in a semi-intensive Stroke Unit (SI-SU) by a scale specifically devised to assess depression in patients with stroke and to identify the symptoms better contributing to the early detection of post stroke depression (PSD). Fifty-four patients admitted to a SI-SU because of suffering from single, first-ever hemispheric stroke were enrolled. Depressive symptoms were assessed by the Post Stroke Depression Rating Scale (PSDRS). All patients were also evaluated by the National Institute of Health Stroke Scale (NIHSS), the modified Rankin scale, the Mini-Mental State Examination (MMSE) and the Frontal Assessment Battery (FAB). The PSDRS detected depressive symptoms in twenty-two patients (40%). The PSDRS scores were not influenced by severity of stroke, functional outcome, site of lesion and type of stroke. Three psychopathological factors were identified inside the PSDRS: "reactivity", "melancholic" and "apathetic", with significant inverse correlations with cognitive measures found only with the "apathetic" factor Less than one-half items of the PSDRS were able to identify overt depressive symptoms. Depressive symptoms are a frequent and early complication in patients referred to a SI-SU with the PSDRS being a suitable tool to detect depressive symptoms in acute phases of stroke.

SPECT imaging of GABA(A)/benzodiazepine receptors and cerebral perfusion in mild cognitive impairment.

PURPOSE: The involvement of neocortical and limbic GABA(A)/benzodiazepine (BZD) receptors in Alzheimer's disease (AD) is controversial and mainly reported in advanced stages. The status of these receptors in the very early stages of AD is unclear and has not been explored in vivo. Our aims were to investigate in vivo the integrity of cerebral cortical GABA(A)/BZD receptors in subjects with amnestic mild cognitive impairment (MCI) and to compare possible receptor changes to those in cerebral perfusion. METHODS: [(123)I]Iomazenil and [(99m)Tc]HMPAO SPECT images were acquired in 16 patients with amnestic MCI and in 14 normal elderly control subjects (only [(123)I]iomazenil imaging in 5, only [(99m)Tc]HMPAO imaging in 4, and both [(123)I]iomazenil and [(99m)Tc]HMPAO imaging in 5). Region of interest (ROI) analysis and voxel-based analysis were performed with cerebellar normalization. RESULTS: Neither ROI analysis nor voxel-based analysis showed significant [(123)I]iomazenil binding changes in MCI patients compared to control subjects, either as a whole group or when considering only those patients with MCI that converted to AD within 2 years of clinical follow-up. In contrast, the ROI analysis revealed significant hypoperfusion of the precuneus and posterior cingulate cortex in the whole group of MCI patients and in MCI converters as compared to control subjects. Voxel-based analysis showed similar results. CONCLUSION: These results indicate that in the very early stages of AD, neocortical and limbic neurons/synapses expressing GABA(A)/BZD receptors are essentially preserved. They suggest that in MCI patients functional changes precede neuronal/synaptic loss in neocortical posterior regions and that [(99m)Tc]HMPAO rCBF imaging is more sensitive than [(123)I]iomazenil GABA(A)/BZD receptor imaging in detecting prodromal AD.

CD33 and SIGLECL1 Immunoglobulin Superfamily Involved in Dementia.

Sialic acid-binding immunoglobulin-type lectins, which are predominantly expressed in immune cells, represent a family of immunomodulatory receptors with inhibitory and activating signals, in both healthy and disease states. Genetic factors are important in all forms of dementia, especially in early onset dementia. CD33 was recently recognized as a genetic risk factor for Alzheimer disease (AD). Here, we present a 2-generation family with 4 members, the father and the 3 siblings, characterized by an early form of unusual dementia exhibiting a behavioral variant close to behavioral variant frontotemporal dementia phenotype and severe forms of memory loss suggestive of AD. We analyzed the CD33 gene in this family and identified 10 single nucleotide polymorphisms (SNPs) in a linkage disequilibrium block associated with the disease. We also identified a tag SNP, rs2455069-A>G, in CD33 exon 2 that could be involved with dementia risk. Additionally, we excluded the presence of C9orf72 expansion mutations and other mutations previously associated with sporadic FTD and AD. The tag SNP association was also analyzed in selected sporadic AD patients from the same Southern Italy region. We demonstrate that CD33 and SIGLECL1 have a significantly increased level of expression in these patients.

Time of isolation, education and gender influence the psychological outcome during COVID-19 lockdown in caregivers of patients with dementia.

PURPOSE: The study evaluated the effects of the COVID-19 emergency lockdown on the psychological outcome in caregivers (children or spouses) of patients with dementia and the loss of the welfare services in these patients. METHODS: Zung's depression and anxiety assessment scales and the Perceived Stress Scale were administered by a telephone interview or a self-compilation directly on the online platform. RESULTS: The sample consisted of 239 participants (men = 124; women = 115) with a mean age of 54.4 years (SD = 12.1). Education was associated with significantly lower overall anxiety and depression scores while days of isolation and female gender were associated with the higher scores. A marked reduction of health services was observed in all patients. CONCLUSION: The lockdown registered a particular impact on people with dementia and their caregivers. Many people with dementia were deprived of care services and time of isolation had a significant negative effect on anxiety and depression in caregivers.

Fronto-temporal dementia presenting as Geschwind's syndrome.

Geschwind described a syndrome (Geschwind syndrome, GS) in patients with temporal lobe epilepsy, characterized by sexual behavioural disorders, hyper-religiosity, hypergraphia and viscosity. In this report we describe a patient affected by fronto-temporal dementia (FTD), who showed all the personality changes of GS without having epilepsy, and suggest that clinicians should be aware of several other features in FTD, such as hyposexuality and hypergraphia, which are usually not noted during the diagnostic evaluation.

In vivo imaging of neurotransmission and brain receptors in dementia.

Positron emission tomography (PET) and single photon emission tomography (SPECT) are the most sensitive techniques to study, in vivo, neurotransmitter systems in normal human brain and in diseases. These methods have been applied over the last years to explore the integrity of cholinergic, serotonergic, GABAergic, and dopaminergic systems in Alzheimer's disease (AD) and in other dementias. The results of these investigations have provided new insights into the neurotransmission involvement in these disorders. Moreover, these methods provide objective quantitative markers for monitoring the progression of disease and the effects of therapies. The pathophysiological and clinical relevance of results from these studies are reviewed and the potential role in early and differential diagnosis discussed. New emerging radiotracers/methods for future investigations of neurochemical processes are delineated.

Mental status impairment in patients with West Haven grade zero hepatic encephalopathy: the role of HCV infection.

BACKGROUND: In patients with cirrhosis, subclinical hepatic encephalopathy, which negatively affects the activity of daily living, is often unidentified. In a multicenter observational study, we investigated the possibility of detecting minimal neurological changes consistent with subclinical hepatic encephalopathy by using the Trail Making Test in a cohort of patients with liver cirrhosis at hospital admission. METHODS: Seventy-seven consecutive patients with liver cirrhosis were studied (mean age, 69.5 +/- 9.1; 95% confidence interval, 67.5-71.6 years). In all patients, possible encephalopathy was investigated according to the West Haven criteria. All those free of any sign of encephalopathy (West Haven 0) were also studied by the Trail Making Test forms A and B. The Child-Pugh score was determined in all patients, and results were compared with the West Haven stage. Exclusion criteria were use of benzodiazepine, beta adrenergic blockers, alcohol, or antiepileptic drugs, or coexistence of depression, dementia, Parkinson's disease, or chronic or acute cerebral vasculopathy. RESULTS: Of the 77 patients, 44 (57.1%, 23 men and 21 women) had West Haven score 0, but among these, 26 (59.1%) were diagnosed with mental impairment likely linked to minimal hepatic encephalopathy. Severity of liver disease correlated with the presence of likely minimal hepatic encephalopathy, because the prevalence of abnormal Trail Making Test results increased from 22.2% in Child-Pugh A, to 63.4% and 74.0% in Child-Pugh B and C, respectively. CONCLUSIONS: The investigation of patients with cirrhosis by the West Haven test is not sufficient to identify subclinical forms of encephalopathy. The Trail Making Test (a simple, inexpensive test) in our series evidenced poor psychometric performance in more than half of the patients who were free of manifest encephalopathy. Subclinical hepatic encephalopathy was present mostly in patients with HCV-related cirrhosis. Detecting minimal hepatic encephalopathy in patients with cirrhosis may help improve their quality of life.

Autobiographical recall training in elderly adults with subjective memory complaint: a pilot study.

Subjective memory complaint is a self-reported memory impairment which affects elderly people. This problem does not interfere with daily living activities but could decrease quality of life. This study's purpose was to verify whether a specific, newly developed, autobiographical recall training could modify self-perception of memory of subjects with subjective memory complaint. Seven elderly subjects (4 women and 3 men; mean age 65.5 yr., SD=11) with such complaint, evidenced through a specific questionnaire, attended the training course and were prospectively assessed on standard neuropsychological tests, depressive symptomatology, and self-perception of memory. Self-perception of memory, as assessed by scores on a formalized questionnaire, improved significantly after the training, while depressive symptoms did not change. Neuropsychological performances were normal before and after the training, but a statistically significant improvement was observed only on the phonological fluency test. Thus the present pilot study suggested that the training may be effective in improving self-perception of memory and metamnestic capacity in elderly people with subjective memory complaints but not in changing subjects' depressive symptoms. This requires replication of this work with a much larger sample so statistical power is adequate.

GRN deletion in familial frontotemporal dementia showing association with clinical variability in 3 familial cases.

Progranulin (GRN) gene mutations have been genetically associated with frontotemporal dementia (FTD) and are present in about 23% of patients with familial FTD. However, the neurobiology of this secreted glycoprotein remains unclear. Here, we report the identification of 3 pedigrees of Southern Italian extraction in whom FTD segregates with autosomal dominant inheritance patterns. We present evidence that all the available patients in these 3 familial cases are carrying the rare GRN gene exon 6 deletion g10325_10331delCTGCTGT (relative to nt 1 inNG_007886.1), alias Cys157LysfsX97. This mutation was previously described in 2 sporadic cases but was never associated with familial cases. Our patients demonstrate heterogeneous clinical phenotypes, such as the behavioral variant (bvFTD) in the affected men and the nonfluent/agrammatic variant of primary progressive aphasia (nfvPPA) in the affected woman. Haploinsufficiency was revealed by both quantitative real-time PCR of the gene and protein analyses. These findings provide further support for a previously proposed role for the GRN gene in the genetic etiology of FTD and its phenotypic variability.

A genome-wide screening and SNPs-to-genes approach to identify novel genetic risk factors associated with frontotemporal dementia.

Frontotemporal dementia (FTD) is the second most prevalent form of early onset dementia after Alzheimer's disease (AD). We performed a case-control association study in an Italian FTD cohort (n = 530) followed by the novel single nucleotide polymorphisms (SNPs)-to-genes approach and functional annotation analysis. We identified 2 novel potential loci for FTD. Suggestive SNPs reached p-values ∼10(-7) and odds ratio > 2.5 (2p16.3) and 1.5 (17q25.3). Suggestive alleles at 17q25.3 identified a disease-associated haplotype causing decreased expression of -cis genes such as RFNG and AATK involved in neuronal genesis and differentiation and axon outgrowth, respectively. We replicated this locus through the SNPs-to-genes approach. Our functional annotation analysis indicated significant enrichment for functions of the brain (neuronal genesis, differentiation, and maturation), the synapse (neurotransmission and synapse plasticity), and elements of the immune system, the latter supporting our recent international FTD-genome-wide association study. This is the largest genome-wide study in Italian FTD to date. Although our results are not conclusive, we set the basis for future replication studies and identification of susceptible molecular mechanisms involved in FTD pathogenesis.

Dysexecutive performance of healthy oldest old subjects on the Frontal Assessment Battery.

BACKGROUND AND AIMS: Frontal lobes and executive functions appear to be more vulnerable to normal aging than other cerebral regions and domains. The aim of the study was to evaluate executive functions by the Frontal Assessment Battery (FAB) in healthy oldest old subjects free of dementia. METHODS: Thirty-two healthy oldest old subjects (age range 85-97 yrs) and 32 young old subjects (aged 61-74 yrs) were studied. All subjects were living with their families or alone and were considered normal, since they were fully independent in their activities of daily living and without signs or symptoms characteristic of any type of dementia. Mental status was assessed by the Mini- Mental State Examination (MMSE) and executive functions by the FAB. RESULTS: Mean MMSE scores were 23.12 ± 4.68 in oldest old and 26.78 ± 2.60 in young old subjects (p<0.005). Delayed recall was the most impaired domain, followed by executive (Serial 7). Mean FAB scores were 9.37 ± 4.14 in the oldest old and 13.53 ± 2.12 in the young old (p<0.0001). Among the FAB subtests, conceptualization was the most impaired in both groups, with sensitivity to interference and inhibitory control exhibiting higher discrimination between the oldest old and young old. Education influenced performance on MMSE and FAB in both groups. CONCLUSIONS: On the FAB test, healthy oldest old subjects showed executive impairment with respect to the young olds, due to the involvement of functions depending on activities of different regions of the frontal lobes. FAB results were consistent with the hypothesis that frontal lobes have a high vulnerability to normal aging. Short composite batteries like the FAB are suitable for rapid and reliable description of patterns of executive functioning in the oldest old.

Clinical, historical and diagnostic findings associated with right ventricular dysfunction in patients with central and non-massive pulmonary embolism.

Right ventricular dysfunction during acute pulmonary embolism (PE) predisposes to hemodynamic instability and cardiogenic shock. Aim of this case-control study was to determine the clinical, historical and diagnostic findings associated with right ventricular dysfunction in patients with acute PE involving the main or segmental pulmonary arteries (central PE) and without hemodynamic instability on admission to the Emergency Department (ED) (non-massive PE). From January 1, 2002 to December 31, 2005, 211 patients with central PE were admitted to the Department of Emergency Medicine of the "Antonio Cardarelli" Hospital (Naples, Italy). One hundred eighteen of them had echocardiographic evidence of right ventricular dysfunction on admission to the ED. A history of type 2 diabetes mellitus and chronic obstructive pulmonary disease were significantly associated with an increased risk of this PE-related complication. Compared to patients without right ventricular dysfunction, those with right ventricular dysfunction showed higher levels of markers of cardiac damage, and a significant impairment of respiratory function. Echocardiographic evidence of right ventricular dysfunction on admission to the ED was significantly associated with the occurrence of hemodynamic instability and cardiogenic shock during the PE clinical course. The study results indicate that a history of type 2 diabetes mellitus and chronic obstructive pulmonary disease are significantly associated with the occurrence of right ventricular dysfunction in patients with non-massive and central PE independent of age, gender and other historical and clinical variables detectable on admission to the ED.

Predictors of in-hospital and long-term clinical outcome in elderly patients with massive pulmonary embolism receiving thrombolytic therapy.

OBJECTIVES: To determine the clinical, historical, and instrumental findings associated with unfavorable short-term and long-term prognosis in elderly patients (>or=65) receiving thrombolytic therapy for pulmonary embolism (PE). DESIGN: Case-control retrospective study. SETTING: General medicine acute care ward. PARTICIPANTS: Sixty-seven elderly patients with PE complicated by hemodynamic instability (massive PE) admitted to the "Antonio Cardarelli" Hospital from January 1, 2002, to December 31, 2004, and evaluated during their hospital stay and 174.4+/-4.6 days after discharge. MEASUREMENTS: PE diagnosis was confirmed using spiral computed tomography angiography. Hemodynamic instability was defined as cardiogenic shock and systolic blood pressure less than 90 mmHg or a pressure drop of 40 mmHg or more for longer than 15 minutes not due to new-onset arrhythmia, hypovolemia, or sepsis. INTERVENTION: Weight-adapted unfractionated heparin and recombinant tissue plasminogen activator. RESULTS: Nine patients (13.4%) died during hospitalization. Higher troponin-I (cTn-I) serum levels at admission to the emergency department and the occurrence of thrombocytopenia after thrombolysis were significantly associated with in-hospital death. Nineteen of the 58 survivors (32.7%) died during follow-up. The risk factors for long-term death were historical findings of cancer and cardiovascular disease at hospital admission. CONCLUSION: Higher cTn-I serum levels in the acute phase and the occurrence of thrombocytopenia after thrombolysis were significantly associated with in-hospital mortality in elderly patients with massive PE. In the same setting, historical findings of cancer and cardiovascular disease are strong predictors of death in the long term.

Troponin I and right ventricular dysfunction for risk assessment in patients with nonmassive pulmonary embolism in the Emergency Department in combination with clinically based risk score.

To determine whether troponin I (cTnI) and right ventricular (RV) dysfunction predict adverse in-hospital outcomes in patients admitted to the Emergency Department (ED) with definite nonmassive pulmonary embolism (PE) independent of and in addition to a recently validated clinical prognostic risk score. From a pool of 168 patients with suspected PE, 89 had nonmassive PE confirmed by spiral lung angio-computed tomography. By the clinical prognostic score, in our study sample, 14% had very low risk; 17% had low risk, 20% had intermediate risk, whereas high risk and very high risk were identified in 29 and 20%, respectively. Prevalence of elevated cTnI (>0.1 microg/L, 57%) at admission was comparable among patients grouped by clinical prognostic score (P = NS); echocardiographic RV dysfunction (54%) was more prevalent with intermediate or high clinical risk score (P < 0.02). Increased cTnI predicted primary end-point (development of hemodynamic instability, overall 33 cases, 37%) independent of and in addition to the clinical risk class and RV dysfunction (P < 0.01 for interaction). Fatal events (12 cases, 14%, 5 definite, 7 possible PE-related) were predicted by higher clinical risk score (P < 0.05). In patients with nonmassive central PE admitted to the ED, increased cTnI contributed to identifying those with increased risk of development of hemodynamic instability independent of and in addition to a validated clinically based risk score.

Increased troponin I predicts in-hospital occurrence of hemodynamic instability in patients with sub-massive or non-massive pulmonary embolism independent to clinical, echocardiographic and laboratory information.

INTRODUCTION: Whether in patients with acute central sub-massive or non-massive pulmonary embolism, mild troponin I increase (>0.03 mug/L) predicts in-hospital occurrence of hemodynamic instability and death independent to prognostically relevant clinical, laboratory and echocardiographic information is not fully established. METHODS AND RESULTS: We evaluated consecutively patients admitted to the Emergency Room for pulmonary embolism; those in stable hemodynamics in whom central pulmonary embolism was confirmed by spiral-computed tomography were recruited. All participants underwent standardized study protocol, including clinical and diagnostic evaluation for assessment of severity of pulmonary embolism; therapy was established accordingly; troponin I was measured, but treatment protocol was not affected by knowledge of troponin I levels. Of 90 patients enrolled in the study, 33 (37%) developed hemodynamic instability during hospitalization (on average, 90 h +/-20 from admission). Troponin I was >0.03 microg/L in 56% of the study population at admission, and predicted occurrence of hemodynamic instability during hospitalization (adjusted hazard ratio 9.8, 95% confidence interval 1.2-79.2), independent to age, gender, co-morbidity, systolic blood pressure, CK-MB, echocardiographic right ventricular dysfunction and other covariates. Twelve patients died during hospitalization (mean time to event 107 h +/-24 from admission); troponin I >0.03 microg/L predicted mortality in univariate analysis, but not after accounting for age, sex and clinical variables. Nevertheless, higher troponin as continuous variable correlated with higher likelihood of in-hospital death (adjusted likelihood ratio 2.2/microg/L, 95% confidence interval 1.1-4.3) in multivariate analysis. In a further multivariate model, CK-MB predicted mortality independent of covariates and troponin I. CONCLUSIONS: In patients with acute central sub-massive or non-massive pulmonary embolism, even mild increase in troponin I >0.03 microg/L may provide relevant short-term prognostic information independent to clinical, laboratory and echocardiographic data.

Role of functional performance in diagnosis of dementia in elderly people with low educational level living in Southern Italy.

BACKGROUND AND AIMS: Diagnosis of dementia is often difficult in subjects with low educational level. Our aim was to evaluate the role of functional performance and the possibility of preferring scores of activities of daily living (ADL) and instrumental activities of daily living (IADL) in screening elderly people for diagnosis of dementia in a rural population of Southern Italy with a very high percentage of non-educated subjects. METHODS: a random sample of 300 residents, out of 1089 subjects over 60 years of age living in San Marcellino (Caserta, Campania), received door-to-door visit for information about their medical history, with clinical evaluation of general geriatric conditions, including the cumulative illness rating scale (CIRS). Dementia was diagnosed if subjects had a Clinical Dementia Rating score (CDR) > or = 1 and according to the criteria of DSMIV, but not according to scores on the Mini Mental State Examination (MMSE), ADL and IADL. Two hundred and nineteen normal subjects (NS) and 75 patients with dementia (DP) were evaluated. RESULTS: in NS, their mean age- and education-corrected MMSE score was 22.15 (lower than the normal cut-off value of 23.8) and 12.60 in DP (p<0.0001). In NS, the mean ADL score was higher than in DP (5.53 vs 2.64, p<0.0001); only age was correlated with ADL scores (coeff=-0.44, t=-4.557, p<0.0001). Assuming age as covariate, ADL scores highly differentiated DP from NS (F(1, 289)=26.083, p<0.0001). In both sexes, mean IADL scores were higher in NS than in DP (4.46 vs 1.80 in men, p<0.0001; 6.85 vs 2.31 in women, p<0.0001). Age and education did not influence IADL scores in men, but age greatly affected performance in women. IADL scores clearly differentiated NS from DP. In NS, a positive correlation was evident between ADL and IADL scores (r=0.234, p<0.0005), but neither scores correlated with the MMSE scores, even when correlation was performed separately for men and women. In DP, a strong correlation was observed between ADL and IADL scores (r=0.709, p<0.0001) and significant correlations were also evident between the scores of MMSE and both ADL (r=0.492,p<0.0001) and IADL (r=0.398, p<0.0004). CONCLUSIONS: in a rural community with a high prevalence of non-educated subjects, cognitive impairment is related to education, whereas independent functioning is limited mainly to age and not to cognition, if the latter remains (relatively) unimpaired. These results point to the importance of an "ecological" approach to the evaluation of elderly people, particularly those living in small rural communities, where education and the social environment may give rise to difficulties in diagnosis of dementia. The assessment of functional autonomy by ADL and IADL scales may be a better screening tool in diagnosing dementia than the MMSE scores.