Syncope and Epilepsy coexist in 'possible' and 'drug-resistant' epilepsy (Overlap between Epilepsy and Syncope Study - OESYS).

BACKGROUND: Differential diagnosis between syncope and epilepsy in patients with transient loss of consciousness of uncertain etiology is still unclear. Thus, the aim of the present work is to evaluate the prevalence of syncope in patients with "possible" or "drug-resistant" epilepsy. METHODS: The Overlap between Epilepsy and SYncope Study (OESYS) is a multicenter prospective observational study designed to estimate the prevalence of syncope in patients followed in Epilepsy Centers for "possible" or "drug-resistant" epilepsy and assessed according the European Society of Cardiology (ESC) guidelines of syncope diagnosis. RESULTS: One hundred seven patients were evaluated; 63 (58.9%) had possible and 44 (41.1%) drug-resistant epilepsy. A final diagnosis of isolated syncope was in 45 patients (42.1%), all with possible epilepsy (45/63, 71.4%). Isolated epilepsy was found in 21 patients (19.6%) and it was more frequent in the drug-resistant than in the possible epilepsy group (34.1% vs. 9.5%, p = 0.002). More importantly, syncope and epilepsy coexisted in 37.4% of all patients but the coexistence was more frequent among patients with drug-resistant than possible epilepsy (65.9% vs. 17.5%, p < 0.001). CONCLUSIONS: Isolated syncope was diagnosed in ≈ 70% of patients with possible epilepsy. Syncope and epilepsy coexisted in ≈ 20% of patients with possible and in ≈ 60% of patients with drug-resistant epilepsy. These findings highlight the need of ESC guidelines of syncope approach in patients with possible and drug-resistant epilepsy.

The Italian version of the "frailty index" based on deficits in health: a validation study.

BACKGROUND AND AIM: Several measurements were taken for frailty classification in geriatric population. "Frailty index" is based on "deficits in health," but it is still not available in Italian version. Thus, the aim of the present work was to validate a version of "frailty index" for the Italian geriatric community. METHODS: The validation of Italian frailty index (IFi) is based on a cohort study that enrolled 1077 non-disabled outpatients aged 65 years or older (81.3 ± 6.5 years) in Naples (Italy). IFi has been expressed as a ratio of deficits present/deficits considered after a comprehensive geriatric assessment. IFi was stratified in light, moderate and severe frailty. Mortality, disability (considering an increase in ADL lost ≥1 from the baseline) and hospitalization were considered at 3, 6, 12, 18 and 24 months of follow-up. Area under curve (AUC) was evaluated for both Fried's and IFi frailty index. RESULT: At the end of follow-up, mortality increased from 1.0 to 30.3%, disability from 40.9 to 92.3% and hospitalization from 0.0 to 59.0% (p < 0.001 for trend). Multivariate analysis shows that the relative risk for unit increase in IFi is 1.09 (95% CI = 1.01-1.17, p = 0.013) for mortality, 1.04 (95% CI = 1.01-1.06, p = 0.024) for disability and 1.03 (95% CI = 1.01-1.07, p = 0.041) for hospitalization. AUC is higher in IFi with respect to Fried's frailty index when considering mortality (0.809 vs. 0.658, respectively), disability (0.800 vs. 0.729, respectively) and hospitalization (0.707 vs. 0.646, respectively). CONCLUSIONS: IFi is a valid measure of frailty after the comprehensive geriatric assessment in an Italian cohort of non-institutionalized patients.

The "syncope and dementia" study: a prospective, observational, multicenter study of elderly patients with dementia and episodes of "suspected" transient loss of consciousness.

BACKGROUND AND AIM: Syncope and related falls are one of the main causes and the predominant cause of hospitalization in elderly patients with dementia. However, the diagnostic protocol for syncope is difficult to apply to patients with dementia. Thus, we developed a "simplified" protocol to be used in a prospective, observational, and multicenter study in elderly patients with dementia and transient loss of consciousness suspected for syncope or unexplained falls. Here, we describe the protocol, its feasibility and the characteristics of the patients enrolled in the study. METHODS: Patients aged ≥65 years with a diagnosis of dementia and one or more episodes of transient loss of consciousness during the previous 3 months, subsequently referred to a Geriatric Department in different regions of Italy, from February 2012 to May 2014, were enrolled. A simplified protocol was applied in all patients. Selected patients underwent a second-level evaluation. RESULTS: Three hundred and three patients were enrolled; 52.6% presented with episodes suspected to be syncope, 44.5% for unexplained fall and 2.9% both. Vascular dementia had been previously diagnosed in 53.6% of participants, Alzheimer's disease in 23.5% and mixed forms in 12.6%. Patients presented with high comorbidity (CIRS score = 3.6 ± 2), severe functional impairment, (BADL lost = 3 ± 2), and polypharmacy (6 ± 3 drugs). CONCLUSION: Elderly patients with dementia enrolled for suspected syncope and unexplained falls have high comorbidity and disability. The clinical presentation is often atypical and the presence of unexplained falls is particularly frequent.

Role of ventricular rate response on dementia in cognitively impaired elderly subjects with atrial fibrillation: a 10-year study.

BACKGROUND: The role of ventricular rate response (VRr) on the incidence of dementia in elderly subjects with cognitive impairment and atrial fibrillation (AF) is not known. Thus, we examined the ability of VRr to predict dementia in cognitively impaired elderly subjects with and without AF. METHODS: A total of 358 cognitively impaired elderly subjects (MMSE <24) with and without AF were stratified in low/high (<50/>90) and moderate (>50/<90 bpm) VRr. A 10-year follow-up was performed. RESULTS: Cognitively impaired subjects with dementia at the end of the follow-up were 135 (37.7%): 33 in the presence (75.0%) and 102 (32.5%) in the absence of AF (p < 0.001). Multivariate analysis shows that AF is a strong predictor of dementia (hazard ratio, HR = 4.10; 95% confidence interval, CI = 1.80-9.30, p < 0.001). More importantly, low/high VRr (<50/>90 bpm) is predictive of dementia in the presence (HR = 7.70, 95% CI = 1.10-14.20, p = 0.03) but not in the absence (HR = 1.85; 95% CI = 0.78-4.47; p = 0.152) of AF. CONCLUSIONS: This study demonstrates that AF predicts dementia in elderly subjects with cognitive impairment. Moreover, VRr seems to play a key role in the incidence of dementia in cognitively impaired elderly subjects with AF.

Depressive symptoms predict mortality in elderly subjects with chronic heart failure.

BACKGROUND: Chronic heart failure (CHF) is characterized by a high mortality in the elderly. Moreover, depression status is also related to poor prognosis in advancing age. Thus, we sought to determine whether depressive status predicts long-term mortality in subject with or without CHF. METHODS AND RESULTS: Long-term mortality after 12-year follow-up in 125 elderly subjects with CHF and 1143 elderly subjects without CHF was studied. Depression was evaluated using the Geriatric Depression Scale (GDS), and all subjects were stratified in tertiles according to GDS score (0-10, 11-20 and 21-30). With increasing GDS score, long-term mortality at the end of follow-up increased from 43·4% to 72·0% in subjects without (P < 0·001) and from 52·6% to 83·9% in subjects with (P < 0·007) CHF. In multivariate analysis, GDS appeared to be predictive of long-term mortality in the absence (Hazard ratio = 1·01; confidence interval 95% 1·00-1·05; P = 0·04) and, even more, in the presence of CHF (Hazard ratio = 1·08; confidence interval 95% 1·01-1·15; P < 0·01). CONCLUSIONS: Depression symptoms predict long-term mortality in elderly subjects without and, even more, with CHF. Thus, depression can be considered a strong predictor of death in CHF elderly subjects.

Atrial Fibrillation in Older Patients with Syncope and Dementia: Insights from the Syncope and Dementia Registry.

OBJECTIVES: To evaluate the clinical characteristics and the long-term outcome of atrial fibrillation (AF) patients with dementia and history of syncope or falls. DESIGN: Observational: analysis of a prospective registry. SETTING AND PARTICIPANTS: Between 2012 and 2016, the Syncope and Dementia Registry enrolled patients in 12 geriatric departments. Follow-up evaluation was at 12 months. MEASURES: Clinical, functional, and cognitive assessment. RESULTS: Of the 522 patients (women, 62.1%; Mini-Mental State Examination 17 ± 6), 26.4% have or presented an AF history. Patients with AF were older (85 ± 6 vs 83 ± 6 years, P = .012), with higher heart rate (78 ± 17 vs. 73 ± 14 bpm, P < .001), prescribed drugs (6.9 ± 2.9 vs 5.9 ± 2.7, P < .001), and an increased number (3.9 ± 2.0 vs 3.0 ± 1.8, P < .001) and severity of comorbidities. Oral anticoagulant therapy was underprescribed (39.9%). Cardiac syncope was more frequently diagnosed (18.8 vs 4.9%, P < .001). At multivariate analysis, AF patients were characterized by advanced age, a higher severity of comorbidities, a greater number of prescribed drugs, an increased heart rate, and a more frequent presence of cardiac symptoms. One-year mortality differed little between patients with and without AF (27.7 vs 22.1%, P = .229). In the arrhythmia group, multivariate predictors of prognosis were disability (number of lost BADLs; P = .020) and a higher heart rate (P = .006). CONCLUSIONS AND IMPLICATIONS: AF and postural stability-related issues often co-exist in persons with dementia. This complex of conditions is associated with an intricate clinical picture, underprescription of oral anticoagulants, and high long-term mortality. Future studies are needed to evaluate the effects of therapy optimization in this population.

Prevalence, predictors and clinical implications of prolonged corrected QT in elderly patients with dementia and suspected syncope.

BACKGROUND: Long QT and use of QT-prolonging drugs are common among older patients receiving polytherapies, but real-world evidence on their impact in clinical practice is controversial. We investigated prevalence, variables associated and clinical implications of prolonged corrected QT (QTc) among patients from the Syncope and Dementia study. METHODS: Observational, prospective, multicenter study. Patients≥65 years with dementia and fall suspected for syncope in the previous three months were enrolled. Several clinical variables and the complete list of medications were recorded for each patient. A 12­lead ECG was obtained and corrected QT was calculated by the Bazett's formula. One-year followup for death and recurrent syncope was performed. RESULTS: Prolonged QTc was observed in 25% of the 432 enrolled patients (mean age 83.3), and was significantly associated with male gender (OR 2.09; 95% CI 1.34-3.26) and diuretics use (OR 1.85; 95% CI 1.18-2.90). At one-year 23.3% of patients died and 30.4% reported at least one recurrent event. Variables associated with one-year mortality were: age, male gender, atrial fibrillation (AF), use of calcium channel blockers and prolonged QTc (OR 1.80; 95% CI 1.01-3.20). Among patients with prolonged QTc a significant interaction for mortality was found with AF. Recurrent events were associated with the use of antiplatelets, cholinesterase. inhibitors and antipsychotics, but not with prolonged QTc. CONCLUSIONS: We documented a high prevalence of prolonged QTc, that was associated with male gender and diuretics but not with psychoactive medications. Patients with prolonged QTc had higher one-year mortality, that was four-fold increased in those with concomitant AF.

Tinetti mobility test is related to muscle mass and strength in non-institutionalized elderly people.

Elderly people are characterized by a high prevalence of falls and sarcopenia. However, the relationship among Tinetti mobility test (TMT) score, a powerful tool to detect elderly people at risk of falls, and sarcopenia is still not thoroughly investigated. Thus, to determine the relationship between TMT score and muscle mass and strength, 337 elderly participants (mean age 77.1 ± 6.9 years) admitted to comprehensive geriatric assessment were enrolled. TMT score, muscle mass by bioimpedentiometer, and muscle strength by grip strength were evaluated. Muscle mass progressively decreased as TMT score decreased (from 15.3 ± 3.7 to 8.8 ± 1.8 kg/m2; p for trend <0.001). Similarly, muscle strength decreased progressively as Tinetti score decreased (from 34.7 ± 8.0 to 23.7 ± 8.7 kg; p for trend 0.001). Linear regression analysis demonstrated that TMT score is linearly related with muscle mass (y = 4.5x + 0.4, r = 0.61; p < 0.01) and strength (y = 14.0x + 0.8, r = 0.53; p < 0.01). Multivariate analysis confirms the strong relationship between the TMT score and muscle mass (r = 0.48, p = 0.024) and strength (r = 0.39, p = 0.046). The present study indicates that TMT score is significantly related to muscle mass and strength in non-institutionalized elderly participants. This evidence suggests that TMT score, together with evaluation of muscle mass and strength, may identify sarcopenic elderly participants at high risk of falls.

Cognitive impairment and cardiovascular diseases in the elderly. A heart-brain continuum hypothesis.

The aging population is increasing and, therefore, a higher prevalence of cardiac disease is emerging; including hypertension, coronary artery disease, atrial fibrillation and chronic heart failure. Large cohort studies have revealed a relationship among increased risk for cognitive impairment and dementia in cardiovascular diseases probably due to embolic stroke or chronic cerebral hypoperfusion. Thus, the aim of the present review is to overview the studies that investigate the presence and/or the development of cognitive impairments and dementia in patients with varied types of cardiovascular disease. Finally, a continuum among hypertension, coronary artery disease, atrial fibrillation and chronic heart failure with to the development of cognitive impairment and progression to dementia has been hypothesized.

Clinical frailty and long-term mortality in elderly subjects with diabetes.

Elderly subjects are characterized by a high prevalence of diabetes and clinical frailty. This study aimed to examine the predictive role of clinical frailty on long-term mortality in elderly subjects with and without diabetes. The study evaluated mortality after 12-year follow-up in 188 subjects with diabetes and 1,100 subjects without diabetes selected in 1992. Clinical frailty was assessed according to the "Frailty Staging System" and stratified in tertiles. After 12-year follow-up, mortality was 50.5 % in subjects without and 66.5 % in subjects with diabetes (p < 0.001). With increasing frailty, mortality increases from 57.9 to 79.0 % (p for trend <0.01) in subjects without and from 75.9 to 87.0 % in subjects with diabetes (p for trend <0.001). Multivariate analysis shows that both diabetes (hazard ratio = 1.38; 95 % confidence interval = 1.12-1.95; p = 0.02) and frailty score (hazard ratio = 1.58 for each unit of increase; 95 % confidence interval = 1.41-2.35; p = 0.04) are predictive of long-term mortality. Moreover, when Cox regression analysis was performed by selecting sex, frailty increases the risk of long-term mortality for each unit of increase by 14 % (hazard ratio = 1.14; 95 % confidence interval = 1.10-1.18; p < 0.01) in women and by 60 % in men (hazard ratio = 1.60; 95 % confidence interval = 1.21-2.12; p < 0.001) in the absence and by 31 % (Hazard ratio = 1.31, 95 % confidence interval = 1.03-1.85, p = 0.03) in women and by 60 % in men (hazard ratio = 1.99, 95 % confidence interval = 1.75-3.05, p < 0.001) in the presence of diabetes, respectively. We concluded that diabetes predicts long-term mortality in elderly subjects. Moreover, clinical frailty significantly predicts mortality in subjects without and even more in those with diabetes. This phenomenon is particularly evident in men. Thus, clinical frailty may be considered a new prognostic factor to identify subjects with diabetes at high risk of mortality.

Focus on the intraductal papillary mucinous neoplasm of the pancreas.

Intraductal papillary mucinous neoplasms (IPMNs) are rare pancreatic tumours, accounting for less of 1-2% of all neoplasms of the gland. Main characteristics of IPMNs are their favourable prognosis as these pre-malignant or frankly malignant lesions are usually slow-growing tumours and radical surgery is frequently possible. According with the localization of the lesions, three different entities are identified: the main-duct IPMN (type I), the branch-duct IPMN (type II) and the mixed type (type III, involving both the main pancreatic duct and side branches). IMPNs do not present pathognomonic signs or symptoms. Obstruction of the main pancreatic duct system may cause abdominal pain and acute pancreatitis (single or recurrent episodes). The tumour may be incidentally discovered in asymptomatic patients, particularly in those with branch-duct IPMNs. In clinical practice, any non-inflammatory cystic lesion of the pancreas should be considered as possible IPMN. Computed tomography, magnetic resonance imaging with cholangiopancreatography and endoscopic ultrasonography can localize IPMN and assess its morphology and size. The choice between non-operative and surgical management strictly depends from the risk of malignancy and of the definitively distinction between benign and malignant IPMNs. Main-duct IPMNs are at higher risk of malignant degeneration, especially in older patients; as a consequence no doubt does not exist as concerns the need of surgery for IPMN type I and III. A less aggressive surgical approach as well as the possibility of conservative management have been suggested for asymptomatic, small size (< 3-3.5 cm), branch-duct IPMN.

Six-minute walking test but not ejection fraction predicts mortality in elderly patients undergoing cardiac rehabilitation following coronary artery bypass grafting.

BACKGROUND: Age-related effects on the ability of 6-min walking test (6MWT) and ejection fraction (EF) to predict mortality in coronary artery bypass grafting (CABG) patients undergoing cardiac rehabilitation (CR) is still debated. DESIGN AND METHODS: In order to verify the role of 6MWT and EF on all-cause mortality in patients undergoing CR following CABG, 882 CABG patients undergoing CR stratified in adults (<65 years) and elderly (≥65 years) were studied. RESULTS: At the admission, EF was 52.6 ± 9.1% in adults and 51.3 ± 8.9% in elderly (p = 0.234, NS) while 6MWT was 343.8 ± 93.5 m in adults and 258.9 ± 95.7 m in elderly (p < 0.001). After 42.9 ± 14.1 months follow up, mortality was 8.2% in adults and 10.9% in elderly (p = 0.176, NS). Cox regression analysis shows that EF ≥ 50% and 6MWT ≥300 m are protective on mortality in all CABG patients before CR. However, EF ≥50% in adults (HR 0.18, 95% CI 0.06-0.49, p < 0.005) but not in elderly (HR 1.16, 95% CI 0.45-3.42, p = 0.354, NS) and 6MWT ≥300 m in elderly (HR 0.34, 95% CI 0.10-0.79, p = 0.033) but not in adults (HR 0.76, 95% CI 0.31-2.12, p = 0.654, NS) exert a protective role on mortality. CONCLUSIONS: Our results indicate that both EF ≥ 50% and 6MWT ≥ 300 m independently protect against mortality in CABG patients before CR. However, their protective role is age dependent. In fact, EF ≥ 50% is protective in adults but not in elderly while 6MWT ≥ 300 m is protective in elderly but not in adult patients.

Role of permanent atrial fibrillation (AF) on long-term mortality in community-dwelling elderly people with and without chronic heart failure (CHF).

Permanent AF is characterized by an increased mortality in elderly subjects with CHF. Moreover, AF increased the risk of mortality also in elderly subjects without CHF. Thus, we examined long-term mortality in community-dwelling elderly people with and without CHF. A total of 1332 subjects aged 65 and older were selected from the electoral rolls of Campania, a region of southern Italy. The relationship between AF and mortality during a 12-year follow-up in 125 subjects with CHF and in 1.143 subjects without CHF were studied. Elderly subjects showed a higher mortality in those with respect to those without AF (72.1% vs. 51.8%; p<0.01). Similarly, elderly subjects without CHF showed a higher mortality in those with respect to those without AF (61.8% vs. 49.8%; p<0.05). In contrast, elderly subjects with CHF showed a similar mortality in those with respect to those without AF (74.7% vs. 82.4%; p=0.234). Multivariate analysis shows that AF was predictive of mortality in all elderly subjects (Hazard Risk=HR=1.39, 95% confidence interval (CI)=1.25-2.82; p<0.001). When the analysis was conducted considering the presence and the absence of CHF, AF was strongly predictive of mortality in elderly subjects without CHF (HR=1.95, 95%CI=1.25-4.51; p<0.001) but not in those with CHF (HR=1.12, 95%CI=0.97-3.69; p=0.321). We concluded that AF is able to predict long-term mortality in elderly subjects. Moreover, AF is strongly predictive of long-term mortality in the absence but not in the presence of CHF.

Association between nocturia and falls-related long-term mortality risk in the elderly.

OBJECTIVES: A high falls-related mortality rate in the elderly is not exclusively related to injuries. Moreover, the risk of falls increases with urinary disorders such as nocturia. The aim of this study was to investigate the role of nocturia in falls-related long-term mortality in elderly subjects. DESIGN: Longitudinal study. SETTING AND PARTICIPANTS: The "Osservatorio Geriatrico Regione Campania" was a cross-sectional study performed in 1992 in Campania, a region of Southern Italy. MAIN MEASUREMENTS: Long-term mortality (12 years' follow-up) in 178 elderly subjects (mean age 74.0 ± 6.3 years) with falls and 1110 elderly subjects (mean age 75.2 ± 6.4 years) without falls at baseline was measured. Subjects were then stratified for the presence/absence of nocturia. KEY RESULTS: In our sample, the prevalence of falls was 13.8% and the prevalence of nocturia was 45.7%. Long-term mortality was 51.3% in nonfallers and 62.9% in fallers (P < .05). In the absence of nocturia, long-term mortality was similar in nonfallers and fallers (49.0% vs 46.7%; P = .514, NS). In contrast, in the presence of nocturia, long-term mortality was higher in fallers than in nonfallers (74.5% vs 53.6%; P < .05). Cox regression analysis confirmed the predictive role of falls on long-term mortality in the presence of nocturia (hazard ratio 60; 95% confidence interval 1.01-2.57; P < .05) but not in the absence of nocturia (hazard ratio = 1.27; 95% confidence interval 0.81-1.99; P = .28). CONCLUSIONS: Our data suggest that falls are related to an increased risk of long-term mortality in the elderly much more in the presence of nocturia. This phenomenon is probably related to the high comorbidity that usually affects elderly subjects with nocturia.

Ischemic preconditioning in the younger and aged heart.

Ischemic preconditioning is the effect of brief ischemic episodes which protect the heart from the following more prolonged ischemic episode. This mechanism is effective in younger but not in aged heart. The age-related reduction of ischemic preconditioning has been demonstrated in experimental models and in elderly patients. Preinfarction angina, a clinical equivalent of ischemic preconditioning, reduces mortality in adult but not in elderly patients with acute myocardial infarction. Physical activity or caloric restriction is partially capable to preserve the cardioprotective effect of ischemic preconditioning in the aging heart. More importantly, physical activity and caloric restriction in tandem action completely preserve the protective mechanism of ischemic preconditioning. Accordingly, the protective mechanism of preinfarction angina is preserved in elderly patients with a high grade of physical activity or a low body-mass index. Thus, both physical activity and caloric restriction are confirmed as powerful anti-aging interventions capable to restore age-dependent reduction of a critical endogenous protective mechanism such as ischemic preconditioning.

Role of clinical frailty on long-term mortality of elderly subjects with and without chronic obstructive pulmonary disease.

BACKGROUND AND AIMS: Elderly subjects are characterized by a high prevalence of chronic obstructive pulmonary disease (COPD) and frailty. This study examined the predictive role of frailty on long-term mortality in elderly subjects with and without COPD. METHODS: The study assessed mortality after a 12-year follow-up in 489 subjects with COPD and 799 subjects without COPD, selected in 1992. Frailty was assessed according to the Frailty Staging System scores ranging from 1 to 7. RESULTS: After 12 years' follow-up, mortality was 48.1% in subjects without and 60.7% in subjects with COPD (p<0.001). With increasing frailty, mortality increased from 41.7% to 75.1% (p for trend <0.01) in subjects without and from 54.3% to 97.0% in subjects with COPD (p for trend <0.001). Multivariate analysis showed that both COPD [hazard ratio (HR)=1.34; 95% confidence interval (95% CI)=1.02-1.81; p=0.042] and frailty score (HR=1.69 for each unit of increase; 95% CI=1.42- 2.00; p<0.001) were predictive of long-term mortality. The frailty score also increased the risk of long-term mortality by 34% in the absence of COPD (HR=1.34 for each unit of increase; 95% CI=1.02-1.81; p<0.05) and by 80% in its presence (HR=1.80 for each unit of increase; 95% CI=1.28-2.53; p<0.001). CONCLUSIONS: Long-term mortality was higher in elderly subjects with than in those without COPD. The clinical frailty score also significantly predicted mortality in subjects without and, even more, in those with COPD. Thus, clinical frailty may be considered a new prognostic factor to identify COPD subjects at high risk of mortality.

Waist circumference but not body mass index predicts long-term mortality in elderly subjects with chronic heart failure.

OBJECTIVES: To examine whether waist circumference (WC) and body-mass index (BMI) can predict long-term mortality in elderly subjects with and without chronic heart failure (CHF). DESIGN: Longitudinal evaluation with a 12-year follow-up. SETTING: Campania, a region of southern Italy. PARTICIPANTS: One thousand three hundred thirty-two subjects aged 65 and older selected from the electoral rolls of Campania. MEASUREMENTS: The relationship between WC or BMI and mortality during a 12-year follow-up in 125 subjects with and 1,143 subjects without CHF. RESULTS: Mortality increased as WC increased in elderly subjects without CHF (from 47.8% to 56.7%, P=.01), and the increase was even greater in patients with CHF (from 58.1% to 82.0%, P=.01). In contrast, mortality decreased as BMI increased in elderly subjects without CHF (from 53.8% to 46.1%, P0=.046) but not in those with CHF. According to Cox regression analysis, BMI protected against long-term mortality in the absence but not in the presence of CHF. In the absence of CHF, WC was associated with a 2% increased risk of long-term mortality for each 1-cm greater WC (Hazard Ratio (HR)=1.02, 95% confidence interval (CI)=1.01-1.03; P<.001), versus 5% increased in the presence of CHF (HR=1.06, 95% CI=1.02-1.10; P<.001). CONCLUSION: WC, but not BMI, is predictive of long-term mortality in elderly individuals with CHF and to a lesser extent in those without CHF.

Social support and long-term mortality in the elderly: role of comorbidity.

Several studies have demonstrated a global increase in morbidity and mortality in elderly subjects with low social support or high comorbidity. However, the relationship between social support and comorbidity on long-term mortality in elderly people is not yet known. Thus, the present study was performed to evaluate the relationship between social support and comorbidity on 12-year mortality of elderly people. A random sample of 1288 subjects aged 65-95 years interviewed in 1992 was studied. Comorbidity by Charlson Comorbidity Index (CCI) score and Social Support by a scale in which total score ranges from 0 to 17, assigning to lowest social support the highest score, were evaluated. At 12-year follow-up, mortality progressively increase with low social support and comorbidity increasing (from 41.5% to 66.7% and from 41.2% to 68.3%, respectively; p<0.001). Moreover, low social support progressively increases with comorbidity increasing (and 12.4±2.5 to 14.3±2.6; p<0.001). Accordingly, multivariate analysis shows an increased mortality risk of 23% for each increase of tertile of social support scale (Hazard ratio=HR=1.23; 95% CI=1.01-1.51; p=0.045). Moreover, when the analysis was performed considering different degrees of comorbidity we found that social support level was predictive of mortality only in subjects with the highest comorbidity (HR=1.39; 95% CI=1.082-1.78; p=0.01). Thus, low social support is predictive of long-term mortality in the elderly. Moreover, the effect of social support on mortality increases in subjects with the highest comorbidity.

Role of early symptoms in assessment of syncope in elderly people: results from the Italian group for the study of syncope in the elderly.

OBJECTIVES: To assess the ability of specific early symptoms to predict cardiac and noncardiac syncope in elderly people. DESIGN: Multicenter cross-sectional observational study. SETTING: Inpatient geriatric acute care departments and outpatient clinics. PARTICIPANTS: Two hundred forty-two patients with syncope (mean age 79+/-8) consecutively referred for evaluation of transient loss of consciousness to any of six clinical centers participating in the Italian Group for the Study of Syncope in the Elderly (GIS Study). MEASUREMENTS: All patients were assessed according to European Society of Cardiology Syncope guidelines and interviewed about symptoms and signs present before syncope. RESULTS: One hundred seventy-four of 242 patients (75.4%) had noncardiac syncope, and 34 (14.7%) had cardiac syncope; 165 patients (71.1%) related symptoms before the loss of consciousness. When elderly patients with syncope were stratified for the presence and absence of symptoms, noncardiac syncope showed the highest prevalence of symptoms (75.3%, P<.01). Awareness of being about to faint, sweating, blurred vision, and nausea are more prevalent in noncardiac syncope. Dyspnea is more prevalent in cardiac syncope. All symptoms except awareness of being about to faint and weakness had good specificity, but sensitivity was low for all symptoms considered. Multivariate regression analysis adjusted for sex and age indicated that nausea (relative risk (RR)=3.7, 95% confidence interval (CI)=1.26-11.2), blurred vision (RR=3.5, 95% CI=1.34-9.59), and sweating (RR=2.8, 95% CI=.21-6.89) were predictive of noncardiac syncope. Dyspnea (RR=5.5, 95% CI=1.0-30.2) was the only symptom predictive of cardiac syncope. CONCLUSION: The data show that symptoms such as nausea, blurred vision, and sweating are predictive of noncardiac syncope, whereas only dyspnea is predictive of cardiac syncope in elderly people.