Multimorbidity and functional impairment-bidirectional interplay, synergistic effects and common pathways.

This review discusses the interplay between multimorbidity (i.e. co-occurrence of more than one chronic health condition in an individual) and functional impairment (i.e. limitations in mobility, strength or cognition that may eventually hamper a person's ability to perform everyday tasks). On the one hand, diseases belonging to common patterns of multimorbidity may interact, curtailing compensatory mechanisms and resulting in physical and cognitive decline. On the other hand, physical and cognitive impairment impact the severity and burden of multimorbidity, contributing to the establishment of a vicious circle. The circle may be further exacerbated by people's reduced ability to cope with treatment and care burden and physicians' fragmented view of health problems, which cause suboptimal use of health services and reduced quality of life and survival. Thus, the synergistic effects of medical diagnoses and functional status in adults, particularly older adults, emerge as central to assessing their health and care needs. Furthermore, common pathways seem to underlie multimorbidity, functional impairment and their interplay. For example, older age, obesity, involuntary weight loss and sedentarism can accelerate damage accumulation in organs and physiological systems by fostering inflammatory status. Inappropriate use or overuse of specific medications and drug-drug and drug-disease interactions also contribute to the bidirectional association between multimorbidity and functional impairment. Additionally, psychosocial factors such as low socioeconomic status and the direct or indirect effects of negative life events, weak social networks and an external locus of control may underlie the complex interactions between multimorbidity, functional decline and negative outcomes. Identifying modifiable risk factors and pathways common to multimorbidity and functional impairment could aid in the design of interventions to delay, prevent or alleviate age-related health deterioration; this review provides an overview of knowledge gaps and future directions.

25(OH) vitamin D and functional outcomes in older adults admitted to rehabilitation units: the safari study.

Vitamin D (25(OH)D) deficiency is associated with poor physical performance; little is known about its impact on geriatric rehabilitation. We found a positive non-linear relationship between 25(OH)D and functional gain, stronger in levels < 16 ng/ml (below the cutoff for "deficiency"). An early 25(OH)D dosage may be advisable for this population. INTRODUCTION: Vitamin D (25(OH)D) deficiency is highly prevalent in older people, and it is associated with poor muscular strength and physical performance. Its impact on functional outcomes during geriatric rehabilitation has been poorly studied. We aim to analyze the association between 25(OH)D and functional recovery in geriatric rehabilitation units. METHODS: We conducted a prospective multi-center cohort study including patients ≥ 65 years old admitted to 3 geriatric rehabilitation units in Italy and Spain, after orthopedic events or stroke. Outcomes were absolute functional gain (AFG, discharge-admission Barthel index) and ability to walk (AW) at 3 months after admission. The association between 25(OH)D quartiles (Q1-Q2-Q3-Q4) and outcomes was explored using linear or logistic regression models. RESULTS: We included 420 patients (mean age = 81.2 years [SD = 7.7], 66.4% females, mean 25(OH)D concentration = 13.5 ng/ml [SD = 8.7]) (to convert to nmol/l multiply by 2.496). A non-linear relationship between 25(OH)D and AFG was found, with a stronger association for 25(OH)D levels < 16 ng/ml. Compared to Q1 (25(OH)D ≤ 6 ng/ml), participants in Q3 (25(OH)D 11.5-18.2 ng/ml) had the best AFG and AW (mean AFG [SD], Q1 = 28.9 [27.8], Q2 = 32.5 [23.5], Q3 = 43.1 [21.9], Q4 = 34.5 [29.3], R2 = 7.3%; AW, Q1-Q2 = 80%, Q3 = 91%, Q4 = 86%). Regression models adjusted for potential confounders confirmed these results (AGF Q2, ß = 2.614, p = 0.49; Q3, ß = 9.723, p < 0.01; Q4, ß = 4.406, p = 0.22; AW Q2, OR [95% CI] = 1.84 [0.67-5.33]; Q3, OR [95% CI] = 4.01 [1.35-13.48]; Q4, OR [95% CI] = 2.18 [0.81-6.21]). CONCLUSIONS: In our study, 25(OH)D concentration showed a positive association with functional outcomes at 3 months. The association is stronger below the usual cutoff for "deficiency." Dosage of 25(OH)D concentration may help identify geriatric rehabilitation patients at risk for a worse functional recovery.

Adults with Down syndrome: a comprehensive approach to manage complexity.

BACKGROUND: Down syndrome (DS) is characterised by premature ageing that affects selected organ systems, and persons with this condition can present patterns of co-morbidities and deficits often observed in the older population without DS. However, information on the characteristics of adult persons with DS is limited. The objective of the study is to describe characteristics of adults with DS collected with a standardised, comprehensive assessment instrument. METHODS: Cross-sectional study. Four hundred thirty adults with DS (age range 18/75 years) from three countries (Italy, n = 95; USA, n = 175; and Canada, n = 160). A standardised assessment instrument (interRAI intellectual disability) was used to assess sample characteristics. RESULTS: Mean age ranged from 35.2 (standard deviation 12.0) years in the US sample to 48.8 (standard deviation 9.0) years in the Canadian sample. Most participants in the Italian and US sample were living in private homes, while more than half of those in the Canadian sample were institutionalised. Prevalences of geriatric conditions, including cognitive deficits, disability in the common activities of daily living, symptoms of withdrawal or anhedonia, aggressive behaviour, communication problems, falls and hearing problems were high in the study sample. Gastrointestinal symptoms, skin and dental problems and obesity were also frequently observed. CONCLUSIONS: Adults with DS present with a high level of complexity, which may suggest the need for an approach based on a comprehensive assessment and management that can provide adequate care. Further research is needed to understand better the effectiveness of such an approach in the DS population.

Antidepressants and the risk of arrhythmia in elderly affected by a previous cardiovascular disease: a real-life investigation from Italy.

PURPOSE: The study aimed to fill existing knowledge gaps on the safety of antidepressant drugs (ADs) by estimating the risk of hospitalization for arrhythmia associated with use of selective serotonin reuptake inhibitors (SSRIs) and newer atypical ADs (NAAs) among elderly with previous cardiovascular (CV) events. METHODS: The cohort was composed by 199,569 individuals aged ≥ 65 years from five Italian healthcare territorial units who were discharged for cardiovascular outcomes in the years 2008-2010. The 17,277 patients who experienced hospital admission for arrhythmia during follow-up were included as cases. Odds of current ADs use among cases (i.e., 14 days before hospital admission) was compared with (i) odds of current use of 1:5 matched controls (between-patients case-control) and with (ii) odds of previous use during 1:5 matched control periods (within-patient case-crossover). The risk of arrhythmia associated with ADs current use was modelled fitting a conditional logistic regression. A set of sensitivity analyses was performed to account for sources of systematic uncertainty. RESULTS: Current users of SSRIs and NAAs were at increased risk of arrhythmia with case-control odds ratios (OR) of 1.37 (95% confidence interval, CI 1.18 to 1.58) and 1.41 (1.16 to 1.71) and case-crossover OR of 1.48 (1.20 to 1.81) and 1.72 (1.31 to 2.27). An increased risk of arrhythmia was associated with current use of trazodone (NAA) consistently in case-control and case-crossover designs. CONCLUSIONS: Evidence that current use of SSRIs and NAAs is associated to an increased risk of arrhythmia among elderly with CV disease was consistently supplied by two observational approaches.

Bone mineral density in adults with Down syndrome.

This study analyzed data of bone mineral density (BMD) from a large cohort of adults with Down syndrome (DS). BMD was found to decrease with age more rapidly in these subjects than in the general population, exposing adults with DS to an increased risk of osteoporosis and bone fracture. INTRODUCTION: Down syndrome (DS) in adulthood presents with a high prevalence of osteoporosis. However, in DS, bone mineral density (BMD) can be underestimated due to short stature. Furthermore, the rate of age-related decline in BMD and its association with gender in DS has been rarely evaluated or compared with the general population. The present study is aimed at assessing the variation of BMD with age and gender in a sample of adults with DS and to compare these data with those of the general population, after adjusting for anthropometric differences. METHODS: Adults with DS, aged 18 or older, were assessed dual-energy-X-ray-absorptiometry (DXA) at the femoral neck and at the lumbar spine. They were compared with the general population enrolled in the National Health and Nutrition Examination Survey (NHANES) 2009-2010 dataset. Bone mineral apparent density (BMAD) was calculated for each individual. RESULTS: DXA was evaluated in 234 subjects with DS (mean age 36.93 ± 11.83 years, ranging from 20 to 69 years; 50.4% females). In the lumbar spine both mean BMD (DS 0.880 ± 0.141 vs. NHANES 1.062 ± 0.167, p < 0.001) and BMAD (DS 0.138 ± 0.020 vs. NHANES 0.152 ± 0.020, p < 0.001) were significantly lower in the DS sample than in the NAHNES cohort. The same trend was observed at the femoral neck in both BMD (DS 0.658 ± 0.128 vs. NHANES 0.835 ± 0.137, p < 0.001) and BMAD (DS 0.151 ± 0.030 vs. NHANES 0.159 ± 0.028, p<0.001). Age was associated with lower femoral neck BMAD in both samples; importantly, this association was significantly stronger in the DS sample. In the lumbar spine region, no significant association between BMAD and age could be observed in both samples. CONCLUSIONS: Adults with DS have lower bone mineral density compared to the general population and they experience a steeper decline with age. Early screening programs are needed in DS population.

Thyroid Function and its Implications in Oxidative Stress Influencing the Pathogenesis of Osteoporosis in Adults with Down Syndrome: A Cohort Study.

People with Down syndrome (DS) show lower bone mass density (BMD) and a higher prevalence of hypothyroidism compared to general population. Furthermore, DS is a well-known high oxidative stress (OS) condition because genes involved in OS map on chromosome 21. Thyroid function too is involved in OS. Since both thyroid function and OS lead to lower BMD and osteoporotic fractures, we have explored correlations among BMD, thyroid hormones, and parameters of OS in DS adults. A total of 105 DS patients (48 males; 21-71 years; mean BMI 28.88±7.12 kg/m(2)) were enrolled in a cohort study, 48 of them undergoing thyroid replacement therapy. We evaluated thyroid function, BMD, and total antioxidant capacity (TAC) in blood plasma. TAC was assayed by H2O2-metmyoglobin system, as source of radicals, and by the chromogenous ABTS, with a latency time (LAG) in the appearance of its cation ABTS+proportional to antioxidant concentration. BMD was evaluated with DEXA, using WHO criteria to classify osteoporosis. Low BMD was found in 83.78% of patients. TSH and LAG did not correlate with BMD. Nevertheless, LAG significantly correlates to Z-scores estimated at the lumbar spine (r(2)=0.558; p=0.03) in hypothyroid patients. Our data show that low TAC could be more associated with reduced BMD rather than TSH itself in DS patients and that the OS could have a role in the pathogenesis of osteoporosis regarding the hypothyroid subgroup.

[Pain therapy in German long-term care facilities in a European comparison. Results of the SHELTER study]. / Schmerztherapie in deutschen Pflegeeinrichtungen im europäischen Vergleich. Ergebnisse der SHELTER-Studie.

BACKGROUND: A considerable number of nursing home residents suffering from pain are insufficiently treated. International comparisons of pain management in German (GER) and other European (EU) nursing homes are still lacking. OBJECTIVE: This study compared the treatment of pain in GER and EU nursing homes in order to improve allocation of therapeutic resources. MATERIAL AND METHODS: A cross-sectional study was carried out with 4156 residents assessed using the interRAI instrument for long-term care facilities, including pharmacological and non-pharmacological pain management modalities. Only those residents reporting pain were included in the analyses (n = 1900 from EU and 245 from GER). Descriptive analyses and analyses of correlations between different parameters and pain were performed. RESULTS: More than three quarters of the residents with at least moderate pain received pharmacological treatment (GER: 77.4 % and EU: 79.3 %). Combination therapy (pharmacological and non-pharmacological) was more frequent in Germany (approximately 13 %). Even in cases of moderate to severe pain one third of GER compared to one quarter of the EU residents received either no analgesic treatment or only on a when needed basis (PRN). Differences were also seen in drugs used (GER metamizole). The amount of PRN was higher in Germany (approximately 13 %, alone or in combination). Only 5 % received the recommended level of non-pharmacological treatment. Pain severity and decubitus were identified as important triggers for pharmacological treatment. Non-pharmacological treatment was used less often than analgesics (EU: 39.2 %, GER: 46.8 %). There were no differences regarding administration frequency and intensity of non-pharmacological treatments in residents with or without pain; however, non-pharmacological treatment was used less often in residents with successful pharmacological treatment. CONCLUSION: The data demonstrate significant deficits in the recognition and treatment of pain in residents living in German or other European nursing home facilities. Further scope for improvement is seen in better recognition of relevant pain, in the adequate use of PRN and long-term medication and especially in the use of activating non-pharmacological treatment.

E-learning to improve the drug prescribing in the hospitalized elderly patients: the ELICADHE feasibility pilot study.

BACKGROUND: E-learning is an efficient and cost-effective educational method. AIMS: This study aimed at evaluating the feasibility of an educational e-learning intervention, focused on teaching geriatric pharmacology and notions of comprehensive geriatric assessment, to improve drug prescribing to hospitalized elderly patients. METHODS: Eight geriatric and internal medicine wards were randomized to intervention (e-learning educational program) or control. Clinicians of the two groups had to complete a specific per group e-learning program in 30 days. Then, ten patients (aged ≥75 years) had to be consecutively enrolled collecting clinical data at hospital admission, discharge, and 3 months later. The quality of prescription was evaluated comparing the prevalence of potentially inappropriate medications through Beer's criteria and of potential drug-drug interactions through a specific computerized database. RESULTS: The study feasibility was confirmed by the high percentage (90 %) of clinicians who completed the e-learning program, the recruitment, and follow-up of all planned patients. The intervention was well accepted by all participating clinicians who judged positively (a mean score of >3 points on a scale of 5 points: 0 = useless; 5 = most useful) the specific contents, the methodology applied, the clinical relevance and utility of e-learning contents and tools for the evaluation of the appropriateness of drug prescribing. CONCLUSIONS: The pilot study met all the requested goals. The main study is currently ongoing and is planned to finish on July 2015.

Medication use in Italian nursing homes: preliminary results from the national monitoring system.

Background: The aging population has increased concerns about the affordability, quality, and nature of long-term care for older people, emphasizing the role of nursing homes. Unlike acute hospital and primary care, there is a lack of drug consumption data in long-term care to understand regional or national healthcare policies. Objectives: This study aimed to describe medication consumption by older adults and expenditure in Italian nursing homes (NHs). Methods: Data on drug consumption and costs from the administrative medicine informational flows that detect medicines packages supplied to patients in health facilities and NHs were used. Data on the characteristics of the healthcare residence were from the Italian Health Ministry. Records for the year 2019, selecting the nursing homes exclusively providing elderly or mixed (elderly and disabled) were used. Results: In 2019, the total expenditure on medicines in NHs amounted to 25.38 million euros, the average cost to 1.30 and the expenditure per bed to 436.18 euros. Cardiovascular drugs were the highest-consuming therapeutic class (177.0 defined daily doses-DDDs/100 days of NH stay; 22.2% of total) followed by drugs acting on the alimentary tract and metabolism (167.6% and 21.0%) and blood drugs (160.4% and 20.1%). The treatment of hypertension and heart failure was widely the most frequently used, with the consumption being driven mainly by furosemide and ramipril. Antiulcer drugs were used on average in more than half of the days of NH stay (58.5 DDDs/100 days of NH stay), representing a therapeutic category for which deprescribing initiatives are recommended. On average, almost all patients received a dose of benzodiazepines, antipsychotics and antidepressants (37.6, 35.9, and 17.7 DDDs/100 days of NH stay, respectively), confirming the high prevalence of use for these medicines. Antibiotics reached 6.8 DDDs/100 days of NH stay. Conclusion: The availability of data in this specific setting allows the identification of the main interventions toward improving appropriateness and represents a challenge for drug utilization research. Data from this study suggest that proton pump inhibitors (PPIs), benzodiazepines and antibacterials can be areas of improving prescribing appropriateness.

Sarcopenia: its assessment, etiology, pathogenesis, consequences and future perspectives.

Sarcopenia is a loss of muscle protein mass and loss of muscle function. It occurs with increasing age, being a major component in the development of frailty. Current knowledge on its assessment, etiology, pathogenesis, consequences and future perspectives are reported in the present review. On-going and future clinical trials on sarcopenia may radically change our preventive and therapeutic approaches of mobility disability in older people.

The Relationship between Anaemia and Frailty: A Systematic Review and Meta-Analysis of Observational Studies.

BACKGROUND: There is increasing evidence that frailty may play a role in chronic diseases, but the associations with specific chronic disorders are still unclear. OBJECTIVES: To conduct a systematic review and meta-analysis assessing the association of anaemia and frailty in observational studies. METHODS: The review was performed according to PRISMA guidelines. We searched PubMed, Web of Science, and Embase from 01/01/2002-10/09/2017. Pooled estimates were obtained through random effect models and Mantel-Haenszel weighting. Homogeneity was assessed with the I2 statistic. Publication bias was assessed with Egger's and Begg's tests. RESULTS: Nineteen studies were included; two longitudinal, seventeen cross-sectional. All studies except three reported an association between anaemia and frailty. The pooled prevalence of prefrailty in individuals with anaemia was 49% (95% CI=38-59%; I2=89.96%) and 24% (95% CI=17-31%; I2= 94.78%) for frailty. Persons with anaemia had more than a twofold odds of frailty (pooled OR=2.24 95% CI=1.53-3.30; I2=91.8%). Only two studies longitudinally examined the association between anaemia and frailty, producing conflicting results. CONCLUSIONS: Frailty and prefrailty are common in anaemic persons. Older persons with anaemia have more than a two-fold increased odds of frailty. These results may have clinical implications, as they identify the need to assess frailty in anaemic people and investigate any potential negative effects associated with the co-occurrence of both conditions. Longitudinal research that examines temporal changes in anaemia and effect of treatment are needed to further clarify the relationship between anaemia and frailty.

Does multimorbidity still remain a matter of the elderly: Lithuanian national data analysis.

INTRODUCTION: Multimorbidity - the coexistence of ≥2 chronic conditions in same individual is usually associated with older age. There is an increase in its prevalence at a much younger age, however with very limited research specifying that. OBJECTIVE: To identify age breaking points for the occurrence of multimorbidity. METHODS: The study included patients, who used any healthcare services between the 01/01/2012 and 30/06/2014. Patients were divided into two groups - with single chronic condition and with multimorbidity. Age-specific proportion of multimorbidity, rate of primary and outpatient visits, number of hospitalizations and prescribed reimbursed medications between these groups were analyzed. RESULTS: The study included 452578 patients, 94.63% of them had more than one chronic condition. The risk increase with every consecutive year for developing multimorbidity was between the age of 28 and 39 years. The age breaking point for the rapid increase in hospitalizations was about 29 years in multimorbidity group. The proportion of patients with multimorbidity using expensive medications starts to increase at the age of 41. CONCLUSIONS: The risk of acquiring an additional chronic condition rises exponentially from the age of 29 years and platos between the age of 51 and 57. Patients with multimorbidity require increasing amounts of primary healthcare resources, where patients with single chronic condition require decreasing primary care usage, possibly attributed to successful patient empowerment.

Selenium Concentrations and Mortality among Community-Dwelling Older Adults: Results from IlSIRENTE Study.

BACKGROUND: Selenium has a wide range of pleiotropic effects, influencing redox homeostasis, thyroid hormone metabolism, and protecting from oxidative stress and inflammation. Serum selenium levels are reduced in the older population. OBJECTIVES: to investigate the association of serum selenium levels with all-cause mortality in a sample of community-dwelling older adults. DESIGN AND SETTING: Data are from the 'Invecchiamento e Longevità nel Sirente' (Aging and Longevity in the Sirente geographic area, ilSIRENTE) study, a prospective cohort study that collected information on individuals aged 80 years and older living in an Italian mountain community (n=347). The main outcome was risk of death after ten years of follow-up. PARTICIPANTS AND MEASUREMENTS: Participants were classified according to the median value of selenium (105.3 µg/L) in two groups: high selenium and low selenium. RESULTS: A total of 248 deaths occurred during a 10-year follow-up. In the unadjusted model, low levels of selenium was associated with increased mortality (HR, 0.66; 95% CI 0.51-0.85). After adjusting for potential confounders the relationship remained significant (HR, 0.71; 95% CI 0.54-0.92). CONCLUSIONS: Low serum levels of selenium are associated with reduced survival in elderly, independently of age and other clinical and functional variables.

Frailty Related Factors as Predictors of Functional Recovery in Geriatric Rehabilitation: The Sarcopenia And Function in Aging Rehabilitation (SAFARI) Multi-Centric study.

BACKGROUND: Frailty-related characteristics, such as sarcopenia, malnutrition and cognitive impairment, are often overlooked, both in clinical practice and research, as potential contributors to functional recovery during geriatric rehabilitation. OBJECTIVE: The aim of the study was to identify frailty-related characteristics associated with functional recovery in a cohort of post-orthopedic surgery and post-stroke older adults. DESIGN: Multi-centric cohort study. Participanst and Settings: Patients over 65 years, admitted to three geriatric rehabilitation units, in Spain and Italy, after an orthopedic event or a stroke, from December 2014 to May 2016. MEASUREMENTS: The Absolute Functional Gain (AFG) defined as the difference between Barthel Index score at discharge and at admission, and the Relative Functional Gain (RFG) that represents the percentage of recovery of the function lost due to the event, were selected as outcomes. Both outcomes were analyzed as continuous and dichotomous variables. Analyses were also stratified as diagnostic at admission. RESULTS: We enrolled 459 patients (mean age±SD=80.75±8.21 years), 66.2% women, 69.5% with orthopedic conditions and with a length of stay of 28.8±9.1 days. Admission after a stroke (Odds Ratio=0.36, 95% Confidence Interval=0.22-0.59]) and a better functional status at admission (OR=0.96, 95% CI=0.94-0.97), were associated with a lower likelihood of AFG, while a better pre-event Barthel index (OR=1.03 for each point in score, 95% CI=1.01-1.04), being able to walk (OR=2.07, 95% CI=1.16-3.70), and a better cognitive status at admission (OR=1.05, 95% CI=1.01-1.09), were associated with a higher chance of AFG. Post-stroke patients with delirium at admission had a re-duced chance of AFG (OR=0.25, 95% CI=0.07-0.91]). Patients admitted after an ortho-pedic event with better pre-event functional status (OR=1.04, 95% CI=1.02-1.06) and able to walk at admission (OR=2.79, 95% CI=1.29-6.03]) had an increased chance of AFG. Additionally, in both diagnostics groups, a better handgrip strength increased the chance of RFG. CONCLUSIONS: Among frailty-related variables, physical, cognitive and muscular function at admission could be relevant for functional improvement during geriatric reha-bilitation. If confirmed, this data might orient targeted interventions.

Anticholinergic drugs and physical function among frail elderly population.

Increasing evidence from experimental studies and human observations suggests that drugs with anticholinergic properties can cause physical and mental impairment. The aim of this study was to evaluate the relationship between the use of drugs with anticholinergic activity and measures of physical performance, muscle strength, and functional status in persons aged 80 years or older. Data are from baseline evaluation of 364 subjects enrolled in the ilSIRENTE study. The ilSIRENTE study is a prospective cohort study performed in the mountain community living in the Sirente geographic area (L'Aquila, Abruzzo) in Central Italy. Physical performance was assessed using the physical performance battery score (Short Physical Performance Battery), which is based on three timed tests: 4-meter walking speed, balance, and chair stand tests. Muscle strength was measured by hand grip strength. We defined as anticholinergic drugs all medications for which serum anticholinergic activity was previously demonstrated. Analyses of covariance were performed to evaluate the relationship of anticholinergic drugs with physical function. In the unadjusted model, all the physical performance, muscle strength, and functional measures showed significant associations with the anticholinergic drug use. After adjustment for potential confounders (age, gender, smoking, physical activity level, cognitive performance score, living alone, body mass index, congestive heart failure, lung diseases, diabetes), these associations were weaker but still statistically significant (physical performance battery score: non-users anticholinergic drugs 6.9, SE 0.1, users anticholinergic drugs 6.1, SE 0.2, P=0.05; hand grip strength: non-users anticholinergic drugs 31.3 kg, SE 0.8, users anticholinergic drugs 28.8 kg, SE 1.0, P=0.05; Activities of Daily Living scale score: non-users anticholinergic drugs 1.2, SE 0.1, users anticholinergic drugs 1.6, SE 0.1, P=0.03; Instrumental Activities of Daily Living scale score: non-users anticholinergic drugs 2.7, SE 0.1, users anticholinergic drugs 3.4, SE 0.1, P<0.001). The use of medication with anticholinergic properties is common among community older subjects in Italy. Our results suggest that among old-old subjects the use of anticholinergic drugs is associated with impaired physical performance and functional status.

Pressure ulcer and mortality in frail elderly people living in community.

Pressure ulcer is one of the most common, disruptive and often disabling conditions affecting frail older people. Purposes of the present study are to ascertain the prevalence of pressure ulcer and to explore the relationship between pressure ulcer and the risk of 1-year all-cause mortality in a large population of frail and very old people living in community. This was an observational cohort study. We analyzed data from the Italian Silver Network Home Care project that collected data on patients admitted to home care programs. A total of twelve home health agencies participated in such project evaluating the implementation of the minimum data set for home care (MDS-HC) instrument. A total of 3,103 patients were enrolled in the present study. The prevalence of patients with pressure ulcer was about 18%. During a follow-up of 12 months from the initial MDS-HC assessment, 160 subjects (29%) died in the pressure ulcer group compared to 368 subjects (14%) in the group of patient without pressure ulcer (p<0.001). After adjusting for age, gender and for all the significantly different variables between subjects with and without pressure ulcer at baseline, subjects with pressure ulcer were more likely to die compared to those without pressure ulcer (RR=1.92; 95% Cl 1.52-2.43).

Comparison of human papillomavirus testing and cervical cytology with colposcopic examination and biopsy in cervical cancer screening in a cohort of patients with Sjogren's syndrome.

OBJECTIVE: The purpose of this study was to evaluate women with Sjögren Syndrome by using cervical cytology, colposcopic examination and HPV-DNA testing and to compare these findings with those obtained from the control group. METHOD: A total of 100 women, who were referred to Ege University, School of Medicine, Department of Obstetrics and Gynecology for cervical cytological screening between September 2004 and March 2005 and 33 of whom had Sjögren syndrome were included in this study. The patients were informed and subjected to cervical cytology, colposcopic examination and HPV-DNA testing. Colposcopic biopsy and endocervical canal curettage were carried out in cases of suspicious colposcopic examination and cytological findings. The findings obtained from 33 women with Sjögren syndrome and 67 subjects in the control group were compared. RESULTS: Normal cervical cytology was detected in five women (5.7%), while suspicious cervical cytology was reported in 62 women (92.5%) in the control group. The prevalence of normal cytology in patients with Sjögren syndrome was 93.9% (n = 31), where 6.1% (n = 2) of the women had suspicious cervical cytology findings. HPV-DNA findings were negative in 66 women (98.5%) in the control group, where the test result of one women (1.5%) was positive. HPV-DNA findings of patients with Sjögren syndrome were positive in one women (3%) and negative in 32 (97%). Colposcopic findings were normal in 63 women (94%) in the control group, where abnormal colposcopic findings were observed in four women (6%). Normal colposcopic findings were observed in 32 women (97%) with Sjögren syndrome, while pathological findings were recorded in one woman (3%). Suspicious cervical cytology, positive findings at colposcopic examination and biopsy and positive HPV-DNA tests were observed together in only one 40-year-old woman who was diagnosed with Sjögren syndrome for a period of four years. Prevalence of dyspareunia and vaginal dryness (atrophic vaginitis) symptoms were observed in Sjögren syndrome and control groups as 36.3% and 22.3%, respectively. CONCLUSION: No significant differences were observed between Sjögren syndrome and the control group who were evaluated by using cervical cytology, colposcopic examination and HPV-DNA tests. A higher prevalence of dyspareunia and vaginal dryness were observed in patients with Sjögren syndrome, yet this difference was not considered as significant with respect to either colposcopic or histopathological findings.

Fatigue and sleep disturbance in multiple sclerosis.

Considering the association of sleep disturbance and fatigue in multiple sclerosis (MS), we investigated the presence of sleep disturbances that may be related to fatigue by using objective and subjective measures. We included 27 MS patients with fatigue, 10 MS patients without fatigue and 13 controls. The Pittsburgh sleep quality index score showed significant differences between patient groups and controls. Beck depression inventory scores were significantly higher in fatigued than non-fatigued patients. Comparison of patient groups and controls revealed significant differences for time in bed, sleep efficiency index, sleep continuity index, wake time after sleep onset, total arousal index and periodic limb movement arousal index. Our study confirms that MS causes sleep fragmentation in terms of both macro and microstructure. Fatigue in MS could be partially explained by disruption of sleep microstructure, poor subjective sleep quality and depression.

Lifetime occupation and physical function: a prospective cohort study on persons aged 80 years and older living in a community.

BACKGROUND: Several studies have reported predictors for loss of mobility and impairments of physical performance among frail elderly people. AIM: To evaluate the relationship between lifetime occupation and physical function in persons aged 80 years or older. METHODS: Data are from baseline evaluation of 364 subjects enrolled in the ilSIRENTE study (a prospective cohort study performed in a mountain community in Central Italy). Physical performance was assessed using the physical performance battery score, which is based on three timed tests: 4-metre walking speed, balance, and chair stand tests. Muscle strength was measured by hand grip strength. Lifetime occupation was categorised as manual or non-manual work. RESULTS: Mean age of participants was 85.9 (SD 4.9) years. Of the total sample, 273 subjects (75%) had a history of manual work and 91 subjects (25%) a history of non-manual work. Manual workers had significant lower grip strength and physical performance battery score (indicating worse performance) than non-manual workers. After adjustment for potential confounders (including age, gender, education, depression, cognitive performance scale score, physical activity, number of diseases, hearing impairment, history of alcohol abuse, smoking habit, and haemoglobin level), manual workers had significantly worse physical function (hand grip strength: non-manual workers 32.5 kg, SE 1.4, manual workers 28.2 kg, SE 0.8; physical performance battery score: non-manual workers 7.1, SE 0.4, manual workers 6.1, SE 0.2). CONCLUSIONS: A history of manual work, especially when associated with high physical stress, is independently associated with low physical function and muscle strength in older persons.

Inappropriate Use of Proton Pump Inhibitors in Elderly Patients Discharged from Acute Care Hospitals.

BACKGROUND: Proton-pump inhibitors (PPI) are extensively prescribed in older patients. However, little information is available on factors associated to PPI prescribing patterns among older patients discharged from hospital. OBJECTIVE: To evaluate the appropriateness and clinical correlates of PPI prescription at discharge in a population of 1081 older patients discharged from acute care Italian hospitals. DESIGN: We used data from the CRiteria to Assess Appropriate Medication Use among Elderly Complex Patients (CRIME) study, a multicenter observational study. The appropriateness of PPI prescriptions was defined according to the Italian Medicines Agency (AIFA) rules. Correlates of overprescribing (i.e prescribing without recognized AIFA indications) and underprescribing (i.e. not prescribing despite the presence of recognized AIFA indications) were investigated by logistic regression analysis. RESULTS: Overprescribing was observed in 30% of patients receiving PPIs at discharge. Underprescribing was observed in 11% of patients not receiving PPIs at discharge. Overprescribing of PPIs at discharge was negatively associated with age (OR=0.88, 95%CI=0.85-0.91), depression (OR=0.58, 95%CI=0.35-0.96), use of aspirin (OR=0.03, 95%CI=0.02-0.06) and systemic corticosteroids (OR=0.02, 95%CI=0.01-0.04). The negative association with number of medications (OR=0.95, 95%CI=0.88-1.03) and overall comorbidities (OR=0.92, 95%CI=0.83-1.02) was nearly significant. Conversely, older age (OR=1.09, 95%CI=1.04-1.14), use of aspirin (OR=24.0, 95%CI=11.5-49.8) and systemic corticosteroids (OR=19.3, 95%CI=11.5-49.8) and overall comorbidities (OR=1.22, 95%CI=1.04-1.42) were independent correlates of underprescribing. CONCLUSION: Overprescribing of PPIs is more frequent in younger patients with lower burden of depression, whilst underprescribing is characterized by older age and greater burden of comorbidity and polypharmacy. Hospitalization should be considered as a clue to identify inappropriate use of PPIs and improve appropriateness of prescribing.