Sex-based differences in the comprehensive geriatric assessment in elderly hospitalized patients with non-valvular atrial fibrillation.

Atrial fibrillation (AF) represents the most common supraventricular arrhythmia, with a prevalence of 1-3 % in the world population. Growing evidences show that AF plays an important role as a risk factor for the development of cognitive impairment (CoI) and dementia, depression and functional limitation. The purpose of the study is to evaluate, in a large cohort of elderly hospitalized patients with nonvalvular AF (NVAF) on direct oral anticoagulants (DOACs) therapy, the prevalence of CoI, depression, and functional limitation, and to assess the different variables that may be detrimental or protective on the risk of CoI or functional limitation. 1004 elderly patients were enrolled, 384 men and 620 women, with a mean age of 84±7.1 years. The two groups were comparable for the main study variables, except for age, prevalence of hypertension and CKD, which were higher in women, while ischemic heart disease was higher in men. In addition, the two groups differed in the CHA2DS2VASc score 5.3 ± 1.3 vs 4.2 ± 1.4 pts (p < 0.0001) and HAS-BLED score 2.5 ± 0.7 vs 2.3 ± 0.8 pts (p = 0.009) that were significantly higher in women. Our study revealed that in a cohort of elderly patients hospitalized with AF taking DOACs, CoI and disability are widely represented, and female sex increases the risk of being affected by CoI by about 3-fold, while improvement of functional limitations reduce this risk by about 15 %. In addition, CoI and depressive symptoms increase the risk of functional impairment about 2-fold and 28 % respectively, while antihypertensive and anti-diabetic therapy reduce this risk.

Validation of a Brief Form of the Self-Administered Multidimensional Prognostic Index: The SELFY-BRIEF-MPI Project.

In clinical practice, self-administered and brief tools to promptly identify older people at risk of frailty are required. The Multidimensional Prognostic Index (MPI), derived from the Comprehensive Geriatric Assessment (CGA) seems reliable enough to serve this purpose, but despite the several versions developed over the past 15 years, it lacks a self-administered and brief version. In this study, we aimed to evaluate the agreement between an abbreviated form of the SELFY-MPI (i.e., SELFY-BRIEF-MPI) and the standard version of the MPI. Four Italian hospitals consecutively enrolled outpatients and inpatients >65 years. The sample included 105 participants (mean age = 78.8 years, 53.3% females). Overall, the two versions showed non-statistically significant differences (Standard-MPI 0.42 ± 0.19 vs.. SELFY-BRIEF-MPI 0.41 ± 0.18; p = 0.104) and a very strong correlation (R = 0.86, p < 0.001). The Bland-Altman Plot revealed that only 5/105 measurements (4.76%) were outside the limits of agreement. The accuracy of the SELFY-BRIEF-MPI in identifying frail people (defined as a Standard-MPI > 0.66) was optimal (area under the curve, AUC = 0.90, p < 0.001). To predict multidimensional frailty, a SELFY-BRIEF-MPI score of 0.60 exhibited the greatest sensitivity/specificity ratio. In conclusion, the SELFY-BRIEF-MPI reported a good agreement with the standard version of the MPI, indicating its application in the screening of multidimensional frailty among older people.

Pain Increases the Risk for Sarcopenia in Community-Dwelling Adults: Results From the English Longitudinal Study of Ageing.

BACKGROUND: Pain and sarcopenia are common in older people. Cross-sectional studies have reported a significant association between these two conditions, but cohort studies exploring pain as a potential risk factor for sarcopenia are scarce. Given this background, the aim of the present work was to investigate the association between pain (and its severity) at baseline, and the incidence of sarcopenia over 10 years of follow-up in a large representative sample of the English older adult population. METHODS: Pain was diagnosed using self-reported information and categorized as mild to severe pain at four sites (low back, hip, knee, and feet). Incident sarcopenia was defined as having low handgrip strength and low skeletal muscle mass during the follow-up period. The association between pain at baseline and incident sarcopenia was assessed using an adjusted logistic regression analysis, and reported as odds ratios (ORs) with their 95% confidence intervals (CIs). RESULTS: The 4 102 participants without sarcopenia at baseline had a mean ± standard deviation age of 69.7 ± 7.2 years, and they were mainly male (55.6%). Pain was present in 35.3% of the sample. Over 10 years of follow-up, 13.9% of the participants developed sarcopenia. After adjusting for 12 potential confounders, people with pain reported a significantly higher risk of sarcopenia (OR = 1.46: 95% CI: 1.18-1.82). However, only severe pain was significantly associated with incident sarcopenia, without significant differences across the four sites assessed. CONCLUSIONS: The presence of pain, particularly severe pain, was associated with a significantly higher risk of incident sarcopenia.

Multimorbidity increased the risk of urinary incontinence in community-dwelling adults: Results from the English Longitudinal Study On Ageing.

Multimorbidity (MM) is common in older people. Recent evidence, largely from cross-sectional studies, suggests that MM could be a risk factor for urinary incontinence (UI). For this reason, we aimed to explore the association between MM at baseline and incident UI, and which individual chronic medical conditions/factors might explain the association between MM and UI, using data from the English Longitudinal Study on Ageing, during ten years of follow-up. MM was defined as having two or more chronic medical conditions; the presence of UI was assessed using self-reported information. A logistic regression analysis, adjusted for baseline potential confounders, was used to assess the association between MM and UI, reporting the data as odds ratios (ORs) with their 95 % confidence intervals (CIs). Of 9432 initial participants, 6742 (mean age: 64.8 years; 53.2 % females) without UI at baseline were included in the analysis. MM was present at baseline in 48.8 % of the participants. People with MM had a significantly higher cumulative incidence of UI than their counterparts, leading to a significantly higher risk of UI also after adjusting for potential confounders at baseline (OR = 1.30; 95 % CI: 1.14-1.48). Among the medical conditions, only three were significantly associated with incident UI, namely asthma, Parkinson's disease, and psychiatric disorders. In conclusion, MM at baseline was associated with an increased risk of UI during ten years of follow-up, suggesting that UI is more likely to be present in people with several chronic medical conditions.

Validation of Abbreviated Form of the Multidimensional Prognostic Index (MPI): The BRIEF-MPI Project.

Purpose: To screen multidimensional frailty in older people, using a comprehensive geriatric assessment (CGA) tool such as the multidimensional prognostic index (MPI), is a public health priority. Unfortunately, the screening tools available are not able to capture multidimensional frailty. In this work, we aimed to evaluate in a population of hospitalized and ambulatory older patients, the agreement between an abbreviated form of the MPI (ie, BRIEF-MPI) and the standard/full version. Participants and Methods: All participants included in the study completed both versions of the MPI, brief and full, which share the following domains: 1) basic and 2) instrumental activities of daily living, 3) mobility/risk of pressure sores, 4) cognition, 5) nutrition, 6) comorbidity, 7) social and 8) number of medications. The agreement between the two instruments was reported using either the mean comparisons with a t-test matched sample, a simple correlation analysis and the Bland-Altman methodology. Results: The study sample included 110 participants (mean age=83.2 years, 51.8% women). The mean difference was statistically and clinically irrelevant (mean difference=0.01±0.10; p=0.27). The correlation between brief and full MPI versions was optimal (R=0.82, p<0.0001). Using the Bland-Altman methodology, we observed that only three participants over 110 (=2.73%) were outside the limits of agreement. The accuracy of BRIEF-MPI in predicting multidimensional frailty, as full MPI>0.66, was optimal (area under the curve=0.92, p<0.0001). A BRIEF-MPI value of 0.59 yielded the highest sensitivity and specificity in predicting multidimensional frailty. Conclusion: BRIEF-MPI had a good agreement with the full/standard version of the MPI, making this tool as ideal for the screening of multidimensional frailty in older people.

Nephrosclerosis impacts time trajectory of renal function and outcomes in elderly individuals with chronic kidney disease.

Despite hypertension ranks among the leading causes of chronic kidney disease (CKD), the impact of chronic hypertensive nephropathy, the so-called 'nephrosclerosis' (NS), on CKD progression is often unpredictable, particularly in elderly population. We have conducted a prospective, observational study to define renal function patterns and outcomes in elderly CKD individuals with or without NS. Three hundred four individuals with an already established CKD were categorized according to the etiology of CKD. NS was defined as the presence of CKD associated with long-term essential hypertension, hypertensive retinopathy, left ventricular hypertrophy and minimal proteinuria. Time trajectories in estimated glomerular filtration rate (eGFR) (CKD-Epi) were computed over a 4-year follow-up. In addition, we analyzed the occurrence of a composite outcome of doubling of serum creatinine levels, eGFR reduction ≥25% and/or the need of chronic renal replacement therapy. CKD was secondary to nephrosclerosis (CKD-NS) in 220 (72.3%). In the whole cohort, the average estimated annual GFR slope was 1.8 mL/min/1.73 m2 eGFR decline was slower in CKD-NS as compared with others (1.4 vs 3.4 mL/min/1.73 m2; p<0.001). The composite renal outcome during follow-up occurred less frequently among elderly with CKD-NS (16/204 vs 14/70; p=0.01, crude HR 0.43, 95% CI 0.22 to 0.85) and was associated at logistic analyses with the etiology of CKD, background cardiovascular disease, total and low density lipoproteins (LDL) cholesterol, and glycemia levels (p value was ranging from 0.01 to 0.05). Despite being highly prevalent in the elderly, NS is associated with a more favorable renal disease course as compared with other conditions.

COVID-19 and cardiovascular problems in elderly patients: Food for thought.

The global number of COVID-19 infections, as of December 23, 2020, stood at approximately 79 million, with over 1.7 million deaths. The development of vascular inflammation may also contribute to a hypercoagulable state and endothelial dysfunction in such patients. It is known that multi-organ damage is more likely in patients with sepsis if they develop coagulopathy and that inhibition of thrombin synthesis can have a positive impact in reducing mortality. In this review, we will focus on the protection of the most fragile groups of the population, such as the elderly. This segment of the population will be a key issue and probably of primary interest to all. Biomarkers appear to be extremely useful as an indicator of what is happening from a pathophysiological point of view in the heart, allowing us to better stratify the prognosis of our patients affected by COVID-19, especially in the most severe cases and those with comorbidities.

The multidimensional prognostic index (MPI) for the prognostic stratification of older inpatients with COVID-19: A multicenter prospective observational cohort study.

BACKGROUND: The topic of prognosis in COVID-19 research may be important in adopting appropriate clinical decisions. Multidimensional prognostic index (MPI) is a frailty assessment tool widely used for stratifying prognosis in older people, but data regarding inpatients, affected by COVID-19, are not available. OBJECTIVES: To evaluate whether MPI can predict in-hospital mortality and the admission to intensive care unit (ICU) in older inpatients hospitalized for COVID-19 infection. METHODS: In this longitudinal, Italian, multi-center study, older patients with COVID-19 were included. MPI was calculated using eight different domains typical of comprehensive geriatric assessment and categorized in three groups (MPI 1 ≤ 0.33, MPI 2 0.34-0.66, MPI 3 > 0.66). A multivariable Cox's regression analysis was used reporting the results as hazard ratios (HRs) with 95% confidence intervals (CIs). RESULTS: 227 older patients hospitalized for SARS-CoV-2 infection were enrolled (mean age: 80.5 years, 59% females). Inpatients in the MPI 3 were subjected less frequently than those in the MPI 1 to non-invasive ventilation (NIV). In the multivariable analysis, people in MPI 3 experienced a higher risk of in hospital mortality (HR = 6.30, 95%CI: 1.44-27.61), compared to MPI 1. The accuracy of MPI in predicting in hospital mortality was good (Area Under the Curve (AUC) = 0.76, 95%CI: 0.68-0.83). People in MPI 3 experienced a significant longer length of stay (LOS) in hospital compared to other participants. No association between MPI and ICU admission was found. CONCLUSIONS: Frailty- as assessed by high MPI score - was associated with a significant higher risk of in-hospital mortality, longer LOS, and lower use NIV, whilst the association with ICU admission was not significant. These findings suggest that prognostic stratification by using the MPI could be useful in clinical decision making in older inpatients affected by COVID-19.

Antimitochondrial Antibodies and Primary Biliary Cholangitis in Patients with Polymyalgia Rheumatica/Giant Cell Arteritis.

Background and Objectives: Laboratory liver abnormalities can be observed in patients affected with polymyalgia rheumatica (PMR) and/or giant cell arteritis (GCA), especially with a cholestatic pattern. The first objective of our review article is to discuss the potential link between antimitochondrial antibodies (AMA) and/or primary biliary cholangitis (PBC) and PMR/GCA, according to the evidences of literature. The second objective is to discuss the association of PMR/GCA with the other rheumatic diseases having PBC as a common manifestation. Materials and Methods: A literature search was performed on PubMed and Medline (OVID interface) using these terms: polymyalgia rheumatica, giant cell arteritis, antimitochondrial antibodies, primary biliary cholangitis, primary Sjogren's syndrome, systemic sclerosis, and systemic lupus erythematosus. The search was restricted to all studies and case reports published in any language. Reviews, conference abstracts, comments, and non-original articles were excluded; however, each review's reference list was scanned for additional publications meeting this study's aim. When papers reported data partially presented in previous articles, we referred to the most recent published data. Results and Conclusions: Our literature search highlighted that cases reporting an association between AMA, PBC and PMR/GCA were very uncommon; AMA antigenic specificity had never been detected and biopsy-proven PBC was reported only in one patient with PMR/GCA. Finally, the association of PMR/GCA with autoimmune rheumatic diseases in which PBC is relatively common was anecdotal.

Progress in the risk assessment of hydroxychloroquine in frail elderly people.

Hydroxychloroquine (HCQ) is an antimalarial drug also known to have anti-inflammatory and antiviral effects. The antiviral action of HCQ has been a point of interest for many researchers because of its mechanism of action and the potential use it could have during the current COVID-19 pandemic. However, HCQ can cause QT interval prolongation. The current therapies used in COVID-19 are changing as the pandemic develops. The aim of this article is to promote a validated risk score for QT prolongation in multidimensional assessment of COVID-19 patients, especially in elderly and polypathological patients.

A Retrospective Study on the Benefits of Combined Citicoline, Memantine, and Acetylcholinesterase Inhibitor Treatments in Older Patients Affected with Alzheimer's Disease.

BACKGROUND: Background: Citicoline has been proven to have beneficial effects in patients with cognitive impairment. In previous studies, combined treatment with memantine and acetylcholinesterase inhibitors (AChEIs) maintained cognitive function in patients with Alzheimer's disease (AD) better than memantine or AChEIs alone. OBJECTIVE: To evaluate the effectiveness and safety of a combination therapy of oral citicoline, memantine, and an AChEI in AD when compared with memantine and an AChEI without citicoline. METHODS: This was a retrospective multi-centric case-control study, conducted in Italian Centers for Cognitive Impairment and Dementia. Overall, 170 patients were recruited (34.11%of men, mean age 76,81±4.93 years): 48.8%treated with memantine and donepezil; 48.2%with memantine and rivastigmine; 2.9%with memantine and galantamine. 89 patients (control-group) were treated with memantine and an AChEI, whereas 81 patients (case-group) were treated with oral citicoline 1000 mg/day added to memantine and an AChEI given orally. Cognitive functions, activities of daily living, instrumental activities of daily living, comorbidities, mood and behavioral disturbances were assessed at baseline, month 6, and month 12. RESULTS: In the case group, MMSE score had a statistically significant increasing trend between T0 and T2 (14.88±2.95 versus 15.09±3.00; p = 0.040), whereas in the control group, MMSE score showed a statistically significant decrease trend (14.37±2.63 versus 14.03±2.92 p = 0.024). CONCLUSION: In older patients with AD, a triple therapy with citicoline, memantine, and AChEI was more effective than memantine and AChEI without citicoline in maintaining the MMSE total score after 12 months.

The CITIMERIVA Study: CITIcoline plus MEmantina plus RIVAstigmine in Older Patients Affected with Alzheimer's Disease.

OBJECTIVE: Combined therapy of memantine or acetylcholinesterase inhibitors, with cholinergic precursors such as citicoline, can be effective in Alzheimer's disease. Indeed, they are able to increase the intrasynaptic levels of acetylcholine more than the single drug. Our aim was to evaluate the efficacy and safety of oral citicoline plus memantine plus rivastigmine in patients with Alzheimer's disease. METHODS: This was a multi-centric, retrospective case-control study conducted in Italian Centers for Cognitive Impairment and Dementia on consecutive patients aged 65 years or older affected with Alzheimer's disease. Overall, 104 patients were recruited (27% male, mean age 76.04 ± 4.92 years); 41 (39.42%) treated with citicolin 1000 mg/day given orally + memantine + rivastigmine (Cases) and 63 (60.58%) treated with memantine + rivastigmine (Controls). At baseline (T0), month 6 (T1) and month 12 (T2), cognitive functions were assessed by the Mini Mental State Examination (MMSE), functional dependence by basal Activities (ADL) and Instrumental Activities of Daily Living (IADL), comorbidity by the Cumulative Illness Rating Scale (CIRS), mood by the Geriatric Depression Scale (GDS), and behavioural disturbances by the Neuropsychiatric Inventory (NPI). Adverse events were reported during the study. RESULTS: The difference in MMSE score was not significant when comparing the two groups at T0, T1 or T2. However, in the case group, the MMSE total score showed a statistically significant difference at T0 versus T1 (13.63 ± 2.46 vs. 14.17 ± 2.24; p = 0.008), and at T0 versus T2 (13.63 ± 2.46 vs. 14.32 ± 2.53; p = 0.002). In the control group, no statistical differences were found at baseline (T0), T1 and T2. ADL, IADL, GDS and NPI total score did not improve during the study in either the case or the control group. CONCLUSIONS: In our study we observed absence of a statistically significant difference between case and control groups for the MMSE total scores. However, in the case group in the MMSE total scores, there was a statistically significant increase between the baseline and the end of the study.