Clinical relevance of clonal hematopoiesis in persons aged ≥80 years.

Clonal hematopoiesis of indeterminate potential (CHIP) is associated with increased risk of cancers and inflammation-related diseases. This phenomenon becomes common in persons aged ≥80 years, in whom the implications of CHIP are not well defined. We performed a mutational screening in 1794 persons aged ≥80 years and investigated the relationships between CHIP and associated pathologies. Mutations were observed in one-third of persons aged ≥80 years and were associated with reduced survival. Mutations in JAK2 and splicing genes, multiple mutations (DNMT3A, TET2, and ASXL1 with additional genetic lesions), and variant allele frequency ≥0.096 had positive predictive value for myeloid neoplasms. Combining mutation profiles with abnormalities in red blood cell indices improved the ability of myeloid neoplasm prediction. On this basis, we defined a predictive model that identifies 3 risk groups with different probabilities of developing myeloid neoplasms. Mutations in DNMT3A, TET2, ASXL1, or JAK2 were associated with coronary heart disease and rheumatoid arthritis. Cytopenia was common in persons aged ≥80 years, with the underlying cause remaining unexplained in 30% of cases. Among individuals with unexplained cytopenia, the presence of highly specific mutation patterns was associated with myelodysplastic-like phenotype and a probability of survival comparable to that of myeloid neoplasms. Accordingly, 7.5% of subjects aged ≥80 years with cytopenia had presumptive evidence of myeloid neoplasm. In summary, specific mutational patterns define different risk of developing myeloid neoplasms vs inflammatory-associated diseases in persons aged ≥80 years. In individuals with unexplained cytopenia, mutational status may identify those subjects with presumptive evidence of myeloid neoplasms.

Cognition, function, and prevalent dementia in centenarians and near-centenarians: An individual participant data (IPD) meta-analysis of 18 studies.

INTRODUCTION: There are limited data on prevalence of dementia in centenarians and near-centenarians (C/NC), its determinants, and whether the risk of dementia continues to rise beyond 100. METHODS: Participant-level data were obtained from 18 community-based studies (N = 4427) in 11 countries that included individuals ≥95 years. A harmonization protocol was applied to cognitive and functional impairments, and a meta-analysis was performed. RESULTS: The mean age was 98.3 years (SD = 2.67); 79% were women. After adjusting for age, sex, and education, dementia prevalence was 53.2% in women and 45.5% in men, with risk continuing to increase with age. Education (OR 0.95;0.92-0.98) was protective, as was hypertension (odds ratio [OR] 0.51;0.35-0.74) in five studies. Dementia was not associated with diabetes, vision and hearing impairments, smoking, and body mass index (BMI). DISCUSSION: Among the exceptional old, dementia prevalence remains higher in the older participants. Education was protective against dementia, but other factors for dementia-free survival in C/NC remain to be understood.

How palliative care professionals deal with predicting life expectancy at the end of life: predictors and accuracy.

PURPOSE: To assess the accuracy of hospice staff in predicting survival of subjects admitted to hospice, exploring the factors considered most helpful by the hospice staff to accurately predict survival. METHODS: Five physicians and 11 nurses were asked to predict survival at admission of 827 patients. Actual and predicted survival times were divided into ≤ 1 week, 2-3 weeks, 4-8 weeks, and ≥ 2 months and the accuracy of the estimates was calculated. The staff members were each asked to score 17 clinical variables that guided them in predicting survival and we analyzed how these variables impacted the accuracy. RESULTS: Physicians' and nurses' accuracy of survival of the patients was 46% and 40% respectively. Survival was underestimated in 20% and 12% and overestimated in 34% and 48% of subjects. Both physicians and nurses considered metastases, comorbidities, dyspnea, disability, tumor site, neurological symptoms, and confusion very important in predicting patients' survival with nurses assigning more importance to intestinal symptoms and pain too. All these factors, with the addition of cough and/or bronchial secretions, were associated with physicians' greater accuracy. In the multivariable models, intestinal symptoms and confusion continued to be associated with greater predictive accuracy. No factors appreciably raised nurses' accuracy. CONCLUSIONS: Some clinical symptoms rated as relevant by the hospice staff could be important for predicting survival. However, only intestinal symptoms and confusion significantly improved the accuracy of physicians' predictions, despite the high prevalence of overestimated survival.

Association of renal function with cognition, functional ability and mood in the oldest-old: The 'Health and Anemia study'.

AIM: In this study, the relationship between kidney function, cognitive performance, functional abilities and mood was investigated in a community-dwelling Italian oldest-old population. METHODS: Serum creatinine was used to calculate estimated glomerular filtration rate (eGFR) using the Modification of Diet in Renal Disease formula, for 415 oldest-old without dementia participating in the 'Health and Anemia' study, a prospective, observational cohort study. The cross-sectional associations of kidney function with cognitive performance on several neuropsychological tests, basic and instrumental functional abilities and mood were analyzed using univariate and multivariable linear regression models. RESULTS: Cognitive performance and functional ability significantly worsened with decreasing kidney function. After adjusting for age, sex, education, comorbidity index of the Cumulative Illness Rating Scale (CIRS), body mass index, bone fracture and serum ferritin levels the associations of eGFR categories with basic and instrumental functional abilities continued to be statistically significant whereas that with global cognitive functions did not. No significant independent association was found between renal function and mood. CONCLUSIONS: Oldest-old with reduced kidney function showed greater basic and instrumental functional disabilities, while cognitive function, although decreased with decreasing eGFR, was no longer significantly associated with eGFR categories after adjusting for confounders.

Incidence of dementia in the oldest-old and its relationship with age: The Monzino 80-plus population-based study.

INTRODUCTION: Relationship between age and dementia at extreme old ages is still an open question, yet population-based studies in this high-risk age segment are rare. METHODS: The Monzino 80-plus is a population-based study among residents 80 years and older in the Varese province, Italy. Of 1371 eligible individuals, 1294 (94.4%), of whom 64 are centenarians, were included in the incidence study. RESULTS: Since 2002, 584 new cases of all-cause dementia were identified over 15 years. The overall incidence rate was 7.9 per 100 person-years. Dementia risk rose with age (IRR: 1.06), with the cubic model providing the best fit (R2  = 0.91-0.96). Cumulative incidences of dementia unadjusted and adjusted for competing mortality risk progressively diverged with age. CONCLUSION: Dementia incidence also keeps rising in nonagenarians and centenarians. Slowing down in growing risk of developing dementia with age is mainly attributable to increasing competing risk of death and resulting selective survival of individuals at lower risk of dementia.

Prevalence of dementia in the oldest old: the Monzino 80-plus population based study.

BACKGROUND: Epidemiological studies commonly include too few of the oldest old to provide accurate prevalence rates of dementia in older age groups. Estimates of the number of those affected, necessary for healthcare planning, are thus flawed. The objective is to estimate the prevalence of dementia and levels of dementia severity in a very large population of oldest old and to investigate the relation between age and dementia prevalence in the extreme ages. METHODS: The Monzino 80-plus is a population-based study among residents 80 years or older in Varese province, Italy. Dementia cases were identified using a one-phase design. The survey was conducted in the participant's place of residence, whether home or institution. Both participants and informants were interviewed. Information was available for 2504 of the 2813 residents (89%). RESULTS: In all, 894 individuals (714 women and 180 men) met the Diagnostic and Statistical Manual of Mental Disorders (fourth edition) criteria for dementia, for a standardized prevalence of 25.3% (95% confidence interval [CI]: 23.4, 27.2%), 28.5% (95% CI: 26.2, 30.9) in women and 18.6% (95% CI: 15.2, 21.9) in men. Age-specific prevalence estimates of dementia increased with age from 15.7% at age 80 to 84 years to 65.9% at age 100 years and higher. For women, prevalence continued to rise after age 100 years, from 64.8% at age 100 to 101 years to 76.1% at age 102 to 107 years. After age 85 years prevalence rates tended to rise linearly, on average 2.6% per year in women and 1.8% in men. About 80% of the cases were moderate or severe. The frequency of mild dementia decreased and that of severe dementia increased with age. CONCLUSION: One-quarter of 80-plus year olds are affected by dementia, mostly moderate or severe. Prevalence rates of dementia do not level off, but continue to rise gradually even in the extreme ages.

Epidemiologic Trends in Hospitalized Ischemic Stroke from 2002 to 2010: Results from a Large Italian Population-Based Study.

BACKGROUND: To describe the incidence of ischemic stroke, short-term mortality, recurrences, and prescription patterns. METHODS: Data from administrative health databases of the Lombardy Region from 2002 to 2010 (about 4 million people) were analyzed for stroke incidence and recurrence, mortality, and drug prescriptions after an ischemic stroke. RESULTS: A total of 43,352 patients with a first hospital admission for ischemic stroke were identified. During 8 years, stroke incidence decreased from 3.2 of 1000 to 2.4 of 1000 (P < .001) in people aged 65-74 years, from 7.1 of 1000 to 5.3 of 1000 (P < .001) at ages 75-84 years and from 11.9 of 1000 to 9.4 of 1000 (P < .001) at age 85 years or older. Stroke recurrences dropped by 30% (from 10.0% to 7.0%, P < .001) and 30-day mortality rate also decreased. Prescription trends showed linear increase in antiplatelets and lipid-lowering drugs, respectively, from 60.2% to 65.0% (P < .001) and from 19.1% to 34.6% (P < .001), whereas antihypertensive prescriptions did not change appreciably. Anticoagulant prescription increased in patients with atrial fibrillation, from 64.8% to 72.1% in the 65-74 years age group, (P = .004) and from 40.2% to 53.7% in the 75-84 years age group (P < .001); less than 20% of the 85 years or older age group were treated with anticoagulants (P < .0001). CONCLUSIONS: Stroke incidence, recurrence, and 30-day mortality decreased from 2002 to 2010 concomitant with an increase in prescriptions of secondary stroke prevention drugs.

Changes in prescribing patterns and clinical outcomes in elderly diabetic patients in 2000 and 2010: analysis of a large Italian population-based study.

PURPOSE: To describe prescribing patterns in elderly Italian diabetic patients of the Lombardy Region in 2000 and 2010 using an administrative database. Hospital admissions and mortality were also recorded and compared in the two index years. METHODS: Analyses were performed on the whole cohort of elderly diabetic patients and across age groups. Direct age standardization was done, with data from the Lombardy Region database for 2005 used as reference to compare diabetic populations in the two index years. Logistic regression models were used to analyze changes in hospital admissions and mortality and to calculate odds ratios. RESULTS: Using data retrieved from the Lombardy Region database we identified 176,384 and 283,982 elderly diabetic patients in 2000 and 2010, respectively. The overall rates of patients treated with antidiabetic drugs were 92.5% in 2000 and 97.0% in 2010. Between 2000 and 2010 the prescribing of glibenclamide declined by 30.0% (from 52.9 to 22.9%, p < 0.001) and that of biguanides rose by 17.4 % (from 47.5 to 64.8%, p < 0.001). In 2010 thiazolidinediones, dipeptidyl peptidase-4 inhibitors and incretin mimetic drugs were seldom prescribed. Drugs for cardiovascular prevention rose in all age classes from 2000 to 2010, and the rates of hospital admission overall fell from 32.0 to 26.8% (p < 0.001) during the same period, with the exception of those aged ≥85 years. Between 2000 and 2010 the mortality rate decreased in patients aged 65-74 years (from 3.4 to 2.9%, p < 0.0001) and rose significantly in those aged ≥85 years. CONCLUSIONS: The drug prescription profile of elderly diabetic patients changed from 2000 to 2010, with a tendency toward recommended drugs. These changes may possibly be linked to the decrease in both hospital admissions and mortality in the diabetic group aged 65-74 years.

MGUS and clonal hematopoiesis show unrelated clinical and biological trajectories in an older population cohort.

Monoclonal gammopathy of undetermined significance (MGUS) and clonal hematopoiesis (CH) are 2 preclinical clonal expansions of hematopoietic cells whose prevalence rises with age, reaching almost 10% in people of aged 70 years and older. The increased risk of myeloid malignancies in patients with myeloma is well defined, and the study of the association between CH and MGUS could help explain this phenomenon. Here, we analyzed a fully clinically annotated dataset of 777 older subjects (median age, 91 years) previously screened for prevalence of CH. The prevalence of MGUS and CH was 9.6% and 17.3%, respectively. We detected CH in 9.7% of the patients with MGUS and MGUS in 5.5% of the patients with CH. We did not find a significant correlation between the presence of MGUS and CH. Furthermore, the 2 conditions showed a differential association with clinical and laboratory covariates, suggesting that MGUS and CH may represent age-associated unrelated clonal drifts of hematopoietic cells. Confirmatory studies are needed to assess the relevance of CH in plasma cell disorders. This trial was registered at www.clinicaltrials.gov as #NCT03907553.

A Population-based study of dementia in the oldest old: the Monzino 80-plus study.

BACKGROUND: Despite being the fastest growing and the most cognitively impaired age group, the oldest olds are under-represented in clinical research. The purpose of this study was to describe the design, methods, and baseline characteristics of the survey population and investigate possible differences in demographic, cognitive, functional, and behavioral characteristics between oldest old with and without any performance on cognitive tests and between oldest old alive and those deceased prior to the interview. METHODS: The Monzino 80-plus Study is a prospective door-to-door population-based survey among 80 years or older residents in the municipalities in the province of Varese, Italy. Dementia cases were identified with a one-phase design. Trained psychologists interviewed both the subject and a proxy informant. The interview included a comprehensive standardized questionnaire together with an array of rating scales and a multidomain cognitive battery to assess cognitive and functional ability, behavioral disturbances and mood. RESULTS: Information was available for 2,139 of the 2,428 registered individuals aged 80 years or older. Main baseline characteristics of the population are reported and discussed. In comparison with those living, elderly persons who had died before the first visit were older, had twice the rate of institutionalization, poorer cognitive performance and competence, and significantly greater instrumental and basic functional disability. The percentage of elderly persons, alive at baseline, without Mini-Mental State Examination rose rather evenly with age. Moreover, they had significantly worse cognitive competence and functional ability, and reported higher prevalences of depressive symptoms and problem behaviors than those with Mini-Mental State Examination. CONCLUSIONS: Prospective investigation of a large population of oldest old can contribute significantly to understanding the relations between age, cognitive decline, and dementia occurrence. Use of informant-based instruments in surveys in the oldest old is crucial in assessing everyday functioning and changes, especially in participants with no cognitive test performance available. Failure to include information on deceased elderly would underestimate, increasingly with age, the prevalence of cognitive and functional disability in the elderly population.

Cholinesterase inhibitor use in Alzheimer's disease: the EPIFARM-Elderly Project.

PURPOSE: This study was designed to examine the prevalence of cholinesterase inhibitor (ChEI) use and the proportions of patients treated with ChEIs by using an administrative prescription database of prevalent and incident cases of mild to moderate Alzheimer's disease (AD) in relation to age and duration of therapy. METHODS: A prospective observational study covering individuals aged 65 years or older who received at least one prescription of ChEIs between 1 January 2002 and 31 December 2007 was conducted in three health administrative areas in the Lombardy Region, Italy. RESULTS: The prevalence of those who received at least one prescription for ChEIs rose from 0.5% in 2002 to 0.7% in 2004, reaching a plateau. Among estimated prevalent cases of mild to moderate AD, the prevalence of patients who received at least one prescription of ChEIs varied in different age groups, rising in those over 80 years and falling slightly in those under 80 years, particularly in patients aged 65-69 years (test for trend, p < 0.001). Among estimated incident cases, the percentage of newly treated patients dropped from 12% in 2004 to 8% in 2007, as well as within each age group (test for trend, p < 0.001). In the cohort of incident users, nearly 40% of patients who started treatment in 2004 were still in treatment 3 years later. CONCLUSIONS: The prescription prevalence of ChEIs increased up to 2004, then reached a plateau. This might reflect the practical response of physicians and patients to the controversy and uncertainty surrounding the clinical value of these expensive drugs for the treatment of AD.

Drug utilization and polypharmacy in an Italian elderly population: the EPIFARM-elderly project.

OBJECTIVE: To investigate the prescribing patterns and the prevalence of polypharmacy in community-dwelling elderly people, and to analyze the association of chronic medications and number of drug prescriptions with age and sex. METHODS: All prescriptions for people aged 65 years or older reimbursed by the Italian National Health Service (NHS) and dispensed by retail pharmacies of the 15 local health units (LHU) in the Lombardy Region during 2005 were analyzed. Logistic regression analysis was used to assess the association between drug prescription (overall, chronic drugs, and polypharmacy) and age, sex, and LHU of residence. RESULTS: Eighty-eight percent of the 1 ,767 ,239 analyzed elderly received at least one drug prescription. The overall prescription rate was slightly higher for women than men (odds ratio [OR] 1.20; 95%CI 1.19-1.21). Seventy-six percent of the elderly received at least one chronic drug, 46% were exposed to polypharmacy, and 20% to chronic polypharmacy. At multivariate analysis, age and LHU residence of the elderly were the main determinants of drug exposure. A significant correlation was found between the overall prescription prevalence rate and exposure to chronic drugs and to chronic polypharmacy (r(s) = 0.79, p < 0.0005 and r(s) = 0.84, p < 0.0001, respectively). CONCLUSIONS: Our findings indicate that age and LHU residence of the elderly are the main determinants of drug prescribing, and there is evidence of a significant correlation between the overall prescription prevalence rate and exposure to chronic drugs and to chronic polypharmacy.

The role of diet on the risk of dementia in the oldest old: The Monzino 80-plus population-based study.

BACKGROUND & AIMS: Longevity also carries its dark side of age-related chronic diseases, dementia being one of the worst and the most prevalent. Since dementia lacks effective treatments, preventing or delaying it is highly desirable. Dietary habits and nutrition have been found to be important modifiable risk factors for many chronic diseases, but evidence on the role of diet on the risk of dementia is still limited, particularly among the very old. Aim of the present work is to study the association of the Mediterranean diet and its components with prevalent and incident dementia in the oldest-old. METHODS: We analyzed data from the Monzino 80-plus study, a population-based study in subjects 80 years or older in the Varese province, Italy. A validated food frequency questionnaire was used to collect information on 23 different foods consumed in the previous year. A Mediterranean diet score was calculated and its components were classified into tertiles. Multivariable models for dementia prevalence and incidence were adjusted for demographic and clinical characteristics. RESULTS: Information on nutrition was available for 1390 subjects in the cross-sectional study and 512 subjects in the longitudinal study, mean respective ages 93 and 92. Greater adherence to Mediterranean diet, greater consumption of eggs, fruits and vegetables, carbohydrates, and greater food intake were associated with a lower prevalence of dementia. Increasing number of portions per week and consumption of legumes significantly decreased the incidence of dementia during the 3.6 year mean follow-up: corresponding hazard ratios of highest vs. lowest tertiles (95% confidence intervals) were 0.66 (0.46-0.95) and 0.68 (0.47-0.97), respectively. CONCLUSION: Oldest-old eating less and having diets with less variety and nutrient density were more frequent among subjects with dementia. The longitudinal analysis confirmed oldest-old subjects who eat more portions, as well as those who have a higher intake of legumes, are at decreased risk of developing dementia even though reverse causality cannot be completely ruled out.

Mild anemia and 11- to 15-year mortality risk in young-old and old-old: Results from two population-based cohort studies.

BACKGROUND: Mild anemia is a frequent although often overlooked finding in old age. Nevertheless, in recent years anemia has been linked to several adverse outcomes in the elderly population. Objective of the study was to investigate the association of mild anemia (hemoglobin concentrations: 10.0-11.9/12.9 g/dL in women/men) with all-cause mortality over 11-15 years and the effect of change in anemia status on mortality in young-old (65-84 years) and old-old (80+ years). METHODS: The Health and Anemia and Monzino 80-plus are two door-to-door, prospective population-based studies that included residents aged 65-plus years in Biella municipality and 80-plus years in Varese province, Italy. No exclusion criteria were used. RESULTS: Among 4,494 young-old and 1,842 old-old, mortality risk over 15/11 years was significantly higher in individuals with mild anemia compared with those without (young-old: fully-adjusted HR: 1.35, 95%CI, 1.15-1.58; old-old: fully-adjusted HR: 1.28, 95%CI, 1.14-1.44). Results were similar in the disease-free subpopulation (age, sex, education, smoking history, and alcohol consumption adjusted HR: 1.54, 95%CI, 1.02-2.34). Both age groups showed a dose-response relationship between anemia severity and mortality (P for trend <0.0001). Mortality risk was significantly associated with chronic disease and chronic kidney disease mild anemia in both age groups, and with vitamin B12/folate deficiency and unexplained mild anemia in young-old. In participants with two hemoglobin determinations, seven-year mortality risk was significantly higher in incident and persistent anemic cases compared to constant non-anemic individuals in both age groups. In participants without anemia at baseline also hemoglobin decline was significantly associated with an increased mortality risk over seven years in both young-old and old-old. Limited to the Monzino 80-plus study, the association remained significant also when the risk was further adjusted also for time-varying covariates and time-varying anemia status over time. CONCLUSIONS: Findings from these two large prospective population-based studies consistently suggest an independent, long-term impact of mild anemia on survival at older ages.

Prevalence, incidence and types of mild anemia in the elderly: the "Health and Anemia" population-based study.

BACKGROUND: Hemoglobin concentrations slightly below the lower limit of normal are a common laboratory finding in the elderly, but scant evidence is available on the actual occurrence of mild anemia despite its potential effect on health. The objectives of this study were to estimate the prevalence and incidence of mild grade anemia and to assess the frequency of anemia types in the elderly. DESIGN AND METHODS: This was a prospective, population-based study in all residents 65 years or older in Biella, Italy. RESULTS: Blood test results were available for analysis from 8,744 elderly. Hemoglobin concentration decreased and mild anemia increased steadily with increasing age. Mild anemia (defined as a hemoglobin concentration of 10.0-11.9 g/dL in women and 10.0-12.9 g/dL in men) affected 11.8% of the elderly included in the analysis, while the estimated prevalence in the entire population was 11.1%. Before hemoglobin determination, most mildly anemic individuals perceived themselves as non-anemic. Chronic disease anemia, thalassemia trait, and renal insufficiency were the most frequent types of mild anemia. The underlying cause of mild anemia remained unexplained in 26.4% of the cases, almost one third of which might be accounted for by myelodysplastic syndromes. In a random sample of non-anemic elderly at baseline (n=529), after about 2 years, the annual incidence rate of mild anemia was 22.5 per 1000 person-years and increased with increasing age. CONCLUSIONS: The prevalence and incidence of mild anemia increase with age and mild anemia affects more than one out of ten elderly individuals. Unexplained anemia is common and may be due to myelodysplastic syndromes in some cases.

Association of mild anemia with hospitalization and mortality in the elderly: the Health and Anemia population-based study.

BACKGROUND: Mild anemia is a frequent laboratory finding in the elderly usually disregarded in everyday practice as an innocent bystander. The aim of the present population-based study was to prospectively investigate the association of mild grade anemia with hospitalization and mortality. DESIGN AND METHODS: A prospective population-based study of all 65 to 84 year old residents in Biella, Italy was performed between 2003 and 2007. Data from a total of 7,536 elderly with blood tests were available to estimate mortality; full health information available to evaluate health-related outcomes was available for 4,501 of these elderly subjects. Mild grade anemia was defined as a hemoglobin concentration between 10.0 and 11.9 g/dL in women and between 10.0 and 12.9 g/dL in men. RESULTS: The risk of hospitalization in the 3 years following recruitment was higher among the mildly anemic elderly subjects than among subjects who were not anemic (adjusted hazard ratio: 1.32; 95% confidence interval: 1.09-1.60). Mortality risk in the following 3.5 years was also higher among the mildly anemic elderly (adjusted hazard ratio: 1.86; 95% confidence interval: 1.34-2.53). Similar results were found when slightly elevating the lower limit of normal hemoglobin concentration to 12.2 g/dL in women and to 13.2 g/dL in men. The risk of mortality was significantly increased in mild anemia of chronic disease but not in that due to beta-thalassemia minor. CONCLUSIONS: After controlling for many potential confounders, mild grade anemia was found to be prospectively associated with clinically relevant outcomes such as increased risk of hospitalization and all-cause mortality. Whether raising hemoglobin concentrations can reduce the risks associated with mild anemia should be tested in controlled clinical trials.

Alzheimer special care units compared with traditional nursing home for dementia care: are there differences at admission and in clinical outcomes?

BACKGROUND: Studies comparing Alzheimer Special Care Units (ASCUs) with traditional nursing homes (NHs) have reported conflicting results. OBJECTIVES: To compare the characteristics and the effects on mortality, hospitalization, use of physical restraints, falls, and antipsychotics among patients admitted to ASCUs or to NHs. METHODS: A sequential cohort of patients with dementia was recruited and followed for 18 months in a sample of randomly selected ASCUs and NHs. Data on socio-demographic, cognitive, functional, behavioral, and clinical characteristics, and drug exposure were collected at baseline and at 6-month intervals up to 18 months. RESULTS: A total of 349 patients were enrolled in 35 ASCUs and 81 in 9 NHs. Patients admitted to ASCUs were younger, cognitively and functionally less impaired, but had more behavioral disturbances than those in NH. During follow-up, ASCU patients had a lower risk of hospitalization (odds ratio: 0.67; 95% confidence interval: 0.46-0.99; P=0.04), and use of physical restraints (odds ratio: 0.66; 95% confidence interval: 0.51-0.86; P=0.003), and showed a higher rate of withdrawal of antipsychotics (P=0.003). No difference was found in mortality and falls. Propensity score analysis gives similar results. CONCLUSIONS: This study found that patients with dementia in ASCUs had different baseline clinical and functional characteristics from those in NHs. They had a lower rate of hospitalization and use of physical restraints at 6-month follow-up, and a higher probability of having antipsychotic agents withdrawn.

Relationship between atrial fibrillation and cognitive decline in individuals aged 80 and older.

BACKGROUND: Atrial fibrillation (AF) and dementia are largely prevalent and incident in progressively older subjects, suggesting a link between the two conditions. While in the general population there are several findings supporting a causal relationship between AF and dementia, it is unclear whether or not this association is still present in individuals aged 80 and older. RESULTS: So far, the few studies that analysed this issue did not provide enough evidence supporting the causative role of AF in increasing the risk of cognitive decline or dementia in patients aged 80 and older. Conversely, a relevant role of optimal anticoagulation control in determining a significant reduction in the risk of cognitive decline is suggested, in AF subjects aged 80years or older. CONCLUSIONS: Further data, coming from population-based studies specifically investigating very old individuals and based upon large samples and comprehensive cognitive assessments, are needed to fully elucidate the relationship between AF and dementia in very old individuals.

Prognostic value of degree and types of anaemia on clinical outcomes for hospitalised older patients.

STUDY OBJECTIVE: This study investigated in a large sample of in-patients the impact of mild-moderate-severe anaemia on clinical outcomes such as in-hospital mortality, re-admission, and death within three months after discharge. METHODS: A prospective multicentre observational study, involving older people admitted to 87 internal medicine and geriatric wards, was done in Italy between 2010 and 2012. The main clinical/laboratory data were obtained on admission and discharge. Based on haemoglobin (Hb), subjects were classified in three groups: group 1 with normal Hb, (reference group), group 2 with mildly reduced Hb (10.0-11.9g/dL in women; 10.0-12.9g/dL in men) and group 3 with moderately-severely reduced Hb (<10g/dL in women and men). RESULTS: Patients (2678; mean age 79.2±7.4y) with anaemia (54.7%) were older, with greater functional impairment and more comorbidity. Multivariable analysis showed that mild but not moderate-severe anaemia was associated with a higher risk of hospital re-admission within three months (group 2: OR=1.62; 95%CI 1.21-2.17). Anaemia failed to predict in-hospital mortality, while a higher risk of dying within three months was associated with the degree of Hb reduction on admission (group 2: OR=1.82;95%CI 1.25-2.67; group 3: OR=2.78;95%CI 1.82-4.26) and discharge (group 2: OR=2.37;95%CI 1.48-3.93; group 3: OR=3.70;95%CI 2.14-6.52). Normocytic and macrocytic, but not microcytic anaemia, were associated with adverse clinical outcomes. CONCLUSIONS: Mild anaemia predicted hospital re-admission of older in-patients, while three-month mortality risk increased proportionally with anaemia severity. Type and severity of anaemia affected hospital re-admission and mortality, the worst prognosis being associated with normocytic and macrocytic anaemia.

Risk of dementia and death in patients with atrial fibrillation: A competing risk analysis of a population-based cohort.

BACKGROUND: Previous studies have stated that atrial fibrillation (AF) is associated with a higher risk of dementia. However, none have examined the competition between death and incident dementia in patients with AF. We evaluated the risk of incident dementia in patients with AF in comparison to people without this arrhythmia, considering of the competing risk of death. METHODS: AF and non-AF cohorts were identified using the large administrative database of the Lombardy Region and followed for ten years. Patients with incident dementia were identified if they had an ICD 9 code referring to dementia at hospital discharge or a prescription for any anti-dementia drug. The association of AF with dementia or death was assessed with the multivariable Cox proportional-regression model, sensitivity analysis with a 1:1 propensity score matching and competing-risk analysis. RESULTS: In 2003 a total of 27,431 patients were hospitalized for AF in the Lombardy Region, while the cohort of non-AF counted 1,600,200 people. AF was associated with a higher risk of dementia (17%) and death (51%) at multivariable Cox analysis. These results were confirmed by the model fitted after propensity score matching. However, competing risk analysis found the association between AF and incident dementia was no longer significant (HR 0.99; 95% CI 0.94-1.04). CONCLUSIONS: In this real-world population the association between AF and dementia was no longer statistically significant when death was considered a competing risk.