Rapidly Progressive Malignant Pelvic Perivascular Epithelioid Cell Neoplasm (PEComa) Associated with Eggerthella lenta Bloodstream Infection.

Perivascular epithelioid cell tumors (PEComa) are rare mesenchymal neoplasms composed of cells that express melanocytic and myogenic markers and grow around small blood vessels. PEComa often show benign behaviors but can also be highly aggressive. In frail and more complex patients, many conditions can overlap, compounding the diagnostic and therapeutic difficulties inherent in rare diseases. Moreover, the complexity of modern patients introduces new and significant players in host-microbe interactions, and emerging pathogens represent a relevant challenge to modern healthcare. Among these pathogens is Eggerthella lenta, an anaerobic gram-positive bacterium of the normal gut microbiota associated with life-threatening infections. Here, we present a case of malignant pelvic PEComa with rapid metastatic progression in a 73-year-old man who presented with an E. lenta bloodstream infection. Approaching differential diagnosis with open-mindedness may assist in better imaging interpretation, surgery scheduling, and proper treatment planning. The non-specific clinical presentation might delay timely diagnosis, while the absence of well-consolidated guidelines undermines the accurate management of the disease, for which strict follow-up can favor better outcomes. Progress in diagnostic techniques, such as the implementation of MALDI-TOF (matrix-assisted laser desorption/ionization-time of flight) mass spectrometry for micro-organism identification, helps with a more accurate pathogen diagnosis and characterization. This allows the implementation of the most appropriate therapy, as well as better surveillance of antibiotic resistance, infection prevention, and control measures. Nevertheless, a good dose of wisdom is vital to avoid overlooking potentially harmful pathogens, particularly in frail individuals.

Atypical Presentation of Pill Aspiration in Older Adults with Dysphagia: A Picture Not To Be Forgotten.

Nonconventional clinical presentations of diseases are common in older adults. Even dramatic events, such as foreign body (FB) inhalation, can occur in a subtle and non-specific manner. Pill aspiration is a rare yet overlooked cause of airway injury. It accounts for approximately 7% of all FB aspirations. In contrast, oral dysphagia and polypharmacology, mainly administrated in solid oral dosage forms (SDOF), like tablets and pills, are common conditions in older adults. Herein, we present a case of SDOF aspiration in a 78-year-old man. FB inhalation developed with general clinical deterioration and neurological impairment (delirium) rather than overt respiratory symptoms. Bronchoscopy provided remarkable images of this unexpected finding. Caregivers and healthcare workers must be aware of the risk of SDOF aspiration and adopt proper safety measures. Early recognition and bronchoscopy for diagnostic and therapeutic purposes can be lifesaving in such cases.

Prevalence and Predictors of Persistence of COVID-19 Symptoms in Older Adults: A Single-Center Study.

OBJECTIVES: Symptom persistence weeks after laboratory-confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) clearance is a relatively common long-term complication of Coronavirus disease 2019 (COVID-19). Little is known about this phenomenon in older adults. The present study aimed at determining the prevalence of persistent symptoms among older COVID-19 survivors and identifying symptom patterns. DESIGN: Cross-sectional study. SETTING AND PARTICIPANTS: We analyzed data collected in people 65 years and older (n = 165) who were hospitalized for COVID-19 and then admitted to the Day Hospital Post-COVID 19 of the Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS (Rome, Italy) between April and December 2020. All patients tested negative for SARS-CoV-2 and met the World Health Organization criteria for quarantine discontinuation. MEASURES: Patients were offered multidisciplinary individualized assessments. The persistence of symptoms was evaluated on admission using a standardized questionnaire. RESULTS: The mean age was 73.1 ± 6.2 years (median 72, interquartile range 27), and 63 (38.4%) were women. The average time elapsed from hospital discharge was 76.8 ± 20.3 days (range 25-109 days). On admission, 137 (83%) patients reported at least 1 persistent symptom. Of these, more than one-third reported 1 or 2 symptoms and 46.3% had 3 or more symptoms. The rate of symptom persistence was not significantly different when patients were stratified according to median age. Compared with those with no persistent symptoms, patients with symptom persistence reported a greater number of symptoms during acute COVID-19 (5.3 ± 3.0 vs 3.3 ± 2.0; P < .001). The most common persistent symptoms were fatigue (53.1%), dyspnea (51.5%), joint pain (22.2%), and cough (16.7%). The likelihood of symptom persistence was higher in those who had experienced fatigue during acute COVID-19. CONCLUSIONS AND IMPLICATIONS: Persistent symptoms are frequently experienced by older adults who have been hospitalized for COVID-19. Follow-up programs should be implemented to monitor and care for long-term COVID-19-related health issues.

Physical performance measures and hospital outcomes among Italian older adults: results from the CRIME project.

BACKGROUND: Older adults are a complex population, at risk of adverse events during and after hospital stay. AIM: To investigate the association of walking speed (WS) and grip strength (GS) with adverse outcomes, during and after hospitalization, among older individuals admitted to acute care wards. METHODS: Multicentre observational study including 1123 adults aged ≥ 65 years admitted to acute wards in Italy. WS and GS were measured at admission and discharge. Outcomes were length-of-stay, in-hospital mortality, 1-year mortality and rehospitalisation. Length-of-stay was defined as a number of days from admission to discharge/death. RESULTS: Mean age was 81 ± 7 years, 56% were women. Compared to patients with WS ≥ 0.8 m/sec, those unable to perform or with WS < 0.8 m/sec had a higher likelihood of longer length-of-stay (OR 2.57; 95% CI 1.63-4.03 and 2.42; 95% CI 1.55-3.79) and 1-year mortality and rehospitalization (OR 1.47, 95% CI 1.07-2.01; OR 1.57, 95% CI 1.04-2.37); those unable to perform WS had a higher likelihood of in-hospital mortality (OR 9.59; 95% CI 1.23-14.57) and 1-year mortality (OR 2.60; 95% CI 1.37-4.93). Compared to good GS performers, those unable to perform had a higher likelihood of in-hospital mortality (OR 17.43; 95% CI 3.87-28.46), 1-year mortality ( OR 3.14; 95% CI 1.37-4.93) and combination of 1-year mortality and rehospitalisation (OR 1.46; 95% CI 1.01-2.12); poor GS performers had a higher likelihood of 1-year mortality (OR 1.39; 95% CI 1.03-2.35); participants unable to perform GS had a lower likelihood of rehospitalisation (OR 0.59; 95% CI 0.39-0.89). CONCLUSION: Walking speed (WS) and grip strength (GS) are easy-to-assess predictors of length-of-stay, in-hospital and post-discharge death and should be incorporated in the standard assessment of hospitalized patients.

Should face masks be worn to contain the spread of COVID-19 in the postlockdown phase?

BACKGROUND: In East Asia, face masks are commonly worn to reduce viral spread. In Euope and North America, however, their use has been stigmatised for a long time, although this view has radically changed during the ongoing severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. Notwithstanding this, it is still unclear whether face masks worn by COVID-19 carriers may indeed prevent viral transmission and environmental contamination. The objective of this study was to evaluate the effectiveness of surgical face masks in filtering SARS-CoV-2. METHODS: Four male patients with COVID-19 were recruited for the study. Two patients wore a surgical mask for 5 h, while two others did not. The spread of the virus in the environment was evaluated through the approved Allplex 2019-nCoV assay. RESULTS: In the room with the two patients without surgical masks, the swab performed on the headboard and sides of the beds was positive for SARS-CoV-2 contamination. In the other room, where two patients were wearing surgical masks, all of the swabs obtained after 5 h tested negative. CONCLUSIONS: The results of the current study add to the growing body of literature supporting the use of face masks as a measure to contain the spread of SARS-CoV-2 by retaining potentially contagious droplets that can infect other people and/or contaminate surfaces. Based on the current evidence, face masks should therefore be considered a useful and low-cost device in addition to social distancing and hand hygiene during the postlockdown phase.

Predictive Factors for a New Positive Nasopharyngeal Swab Among Patients Recovered From COVID-19.

INTRODUCTION: As an emerging infectious disease, the clinical and virologic course of COVID-19 requires better investigation. The aim of this study is to identify the potential risk factors associated with persistent positive nasopharyngeal swab real-time reverse transcription‒polymerase chain reaction tests in a large sample of patients who recovered from COVID-19. METHODS: After the acute phase of SARS-CoV-2 epidemic infection, the Fondazione Policlinico A. Gemelli IRCSS of Rome established a post-acute care service for patients discharged from the hospital and recovered from COVID-19. Between April 21 and May 21, 2020, a total of 137 individuals who officially recovered from COVID-19 were enrolled in this study. All patients were tested for the SARS-CoV-2 virus with nucleic acid RT-PCR tests. Analysis was conducted in June 2020. RESULTS: Of the 131 patients who repeated the nasopharyngeal swab, 22 patients (16.7%) tested positive again. Some symptoms such as fatigue (51%), dyspnea (44%), and coughing (17%) were still present in a significant percentage of the patients, with no difference between patients with a negative test and those who tested positive. The likelihood of testing positive for SARS-CoV-2 infection was significantly higher among participants with persistent sore throat (prevalence ratio=6.50, 95% CI=1.38, 30.6) and symptoms of rhinitis (prevalence ratio=3.72, 95% CI=1.10, 12.5). CONCLUSIONS: This study is the first to provide a given rate of patients (16.7%) who test positive on RT-PCR test for SARS-CoV-2 nucleic acid after recovering from COVID-19. These findings suggest that a significant proportion of patients who have recovered from COVID-19 still could be potential carriers of the virus. In particular, if patients continue to have symptoms related to COVID-19, such as sore throat and rhinitis, it is reasonable to be cautious by avoiding close contact, wearing a face mask, and possibly repeating a nasopharyngeal swab.

The Geriatrician: The Frontline Specialist in the Treatment of COVID-19 Patients.

On February 20, 2020, a man living in the north of Italy was admitted to the emergency room with an atypical pneumonia that later proved to be COVID-19. This was the trigger of one of the most serious clusters of COVID-19 in the world, outside of China. Despite aggressive restraint and inhibition efforts, COVID-19 continues to increase, and the total number of infected patients in Italy is growing daily. After 6 weeks, the total number of patients reached 128,948 cases (April 5, 2020), with the higher case-fatality rate (15,887 deaths) dominated by old and very old patients. This sudden health emergency severely challenged the Italian Health System, in particular acute care hospitals and intensive care units. In 1 hospital, geriatric observation units were created, the experience of which can be extremely useful for European countries, the United States, and all countries that in the coming days will face a similar situation.

Heart failure, frailty, and pre-frailty: A systematic review and meta-analysis of observational studies.

Frailty is a syndrome characterized by reduced physiological reserves, increased vulnerability to stressors and adverse health outcomes. Frailty can change the prognosis and treatment approach of several chronic diseases, including heart failure (HF). The aim of this study was to conduct a systematic review and meta-analysis assessing the association of HF with frailty and pre-frailty. We employed PRISMA guidelines for reporting the results. We searched PubMed, Web of Science, and Embase from 01/01/2002 to 29/11/2019.The quality of the studies was evaluated with the Newcastle Ottawa Scale. Pooled estimates were obtained through random-effect models and Mantel-Haenszel weighting. Homogeneity (I2) and publication bias were assessed. We selected 54 studies (52 cross-sectional, one longitudinal, and one with both designs). The pooled prevalence of pre-frailty in individuals with HF was 46% (95% CI = 38-53; I2 = 93.1%) and 40% (95% CI = 31-48; I2 = 97%) for frailty. The proportion of pre-frail individuals with HF was 20% (95%CI = 15-25; I2 = 99.2%) and the proportion of frail individuals with HF was 31% (95% CI = 17-45; I2 = 98.7%). Two studies using the same frailty definition reported estimates for the association between frailty and HF (pooled OR = 3.44; 95% CI = 0.75-15.73; I2 = 95.8%). In conclusion, frailty and pre-frailty are frequent in people with HF. Persons with HF have 3.4-fold increased odds of frailty. Longitudinal studies examining bidirectional pathophysiological pathways between HF and frailty are needed to further clarify this relationship and to assess if specific treatment for HF may prevent or delay the onset of frailty and vice versa.

Untangling the relationship between fat distribution, nutritional status and Parkinson's disease severity.

BACKGROUND: Parkinson's disease (PD) is responsible for significant changes in body composition. AIMS: We aimed to test the association between PD severity and fat distribution patterns, and to investigate the potential modifier effect of nutritional status in this association. METHODS: We enrolled 195 PD subjects consecutively admitted to a university geriatric day hospital. All participants underwent comprehensive clinical evaluation, including assessment of total and regional body composition (dual-energy X-ray absorptiometry, DXA), body mass index, nutritional status (Mini-Nutritional Assessment, MNA), motor disease severity (UPDRS III), comorbidities, and pharmacotherapy. RESULTS: The fully adjusted linear regression model showed a negative association between UPDRS III and total body fat in kg and percentage (respectively, B - 0.79; 95% CI - 1.54 to - 0.05 and B - 0.55; 95% CI - 1.04 to - 0.05), percentage android fat (B - 1.07; 95% CI - 1.75 to - 0.39), trunk-leg fat ratio (B - 0.02; 95% CI - 0.04 to - 0.01), trunk-limb fat ratio (B - 0.01; 95% CI - 0.06 to - 0.01) and android-gynoid fat ratio (B - 0.01; 95% CI - 0.03 to - 0.01). After stratification by MNA score, all the parameters of android-like fat distribution resulted negatively associated (p < 0.001 for all) with UPDRS III, but only among subjects with a MNA < 23.5 (risk of malnutrition or malnutrition). CONCLUSION: We found a negative association between severity of motor impairment and total fat mass in PD, more specific with respect to an android pattern of fat distribution. This association seems to be driven by nutritional status, and is significant only among patients at risk of malnutrition or with overt malnutrition.

Association of Pisa Syndrome With Mortality in Patients With Parkinson's Disease.

OBJECTIVES: In Parkinson's disease, Pisa syndrom (PS) has been associated with disease stage and severity, combined treatment with levodopa and dopamine agonists, gait disorders, and comorbidities. Some forms of PS are potentially reversible; nevertheless, little is known about the impact of this syndrome on survival. DESIGN: Prospective study with a median follow-up of 2 years. SETTING AND PARTICIPANTS: Patients with Parkinson's disease, age 65 years and older (N = 189), attending a geriatric day hospital. MEASUREMENTS: According to established criteria, PS was diagnosed in the presence of at least 10° lateral flexion of the trunk reducible by passive mobilization or supine positioning. Cox regression was adopted to assess the association of PS with all-cause mortality. RESULTS: PS was diagnosed in 40 patients (21%); over the follow-up, 21 (11%) subjects died. In Cox regression, PS was associated with higher mortality [hazard ratio (HR) 4.10; 95% confidence interval (CI) = 1.36-12.38], after adjusting; other variables associated with mortality were age (HR = 1.19, 95% CI = 1.08-1.32), beta blockers (HR = 4.35, 95% CI = 1.23-15.39), and albumin levels (HR = 0.05, 95% CI = 0.01-0.33). The association of PS with mortality remained significant also after adjusting for variables associated with this syndrome (HR = 4.04, 95% CI = 1.33-12.25). CONCLUSIONS/IMPLICATIONS: PS represents a risk factor for earlier mortality in Parkinson's disease; further studies are needed to ascertain the underlying causes and whether treatment of this condition might improve survival.

Prevalence of Impulsive-Compulsive Symptoms in Elderly Parkinson's Disease Patients: A Case-Control Study.

BACKGROUND: Impulse-control disorders (ICDs) are frequently described in patients with Parkinson's disease (PD), particularly among those treated with dopaminergic medications, but data on the prevalence of ICDs in elderly populations are lacking. OBJECTIVE: The aim of this study was to estimate the prevalence of ICDs by using an Italian validation of the Questionnaire for Impulsive-Compulsive Disorders in Parkinson's Disease (QUIP) and to identify associated sociodemographic and clinical factors in a sample of elderly PD patients and in a control group of similarly aged healthy volunteers. METHODS: Using the United Kingdom Parkinson's Disease Society Brain Bank diagnostic criteria, we included 115 consecutive PD and 105 healthy controls. They were recruited from June 2014 to December 2015. All participants completed the self-administered QUIP-Anytime for assessment of ICDs occurring any time during the course of PD. RESULTS: Mean ± SD age was 75.7 ± 7.0 years in the PD patients and 76.1 ± 7.0 years in the control group. The mean disease duration was 6.8 years (range, 1-26 years). Among the PD patients, 44.7% (n = 51) had at least 1 ICD or related disorder compared to 25.2% (n = 26) in the control group (between-group difference: P = .003). Hypersexuality and compulsive shopping were significantly more common in the PD group than in the control group (P < .05). The prevalence of other compulsive behaviors was 42.5% in the PD group and 38.9% in the control group (P = NS). The Italian version of the QUIP-Anytime showed high test-retest reliability (κ > 0.70 for all items). CONCLUSIONS: Our data confirm a high prevalence of ICD symptoms in elderly PD patients, approximately twice that seen in the general population.

Sarcopenia in Parkinson Disease: Comparison of Different Criteria and Association With Disease Severity.

OBJECTIVES: In Parkinson disease (PD), sarcopenia may represent the common downstream pathway that from motor and nonmotor symptoms leads to the progressive loss of resilience, frailty, and disability. Here we (1) assessed the prevalence of sarcopenia in older adults with PD using 3 different criteria, testing their agreement, and (2) evaluated the association between PD severity and sarcopenia. DESIGN: Cross-sectional, observation study. SETTING: Geriatric day hospital. PARTICIPANTS: Older adults with idiopathic PD. MEASUREMENTS: Body composition was evaluated through dual energy x-ray absorptiometry. Handgrip strength and walking speed were measured. Sarcopenia was operationalized according to the Foundation for the National Institutes of Health, the European Working Group on Sarcopenia in Older Persons, and the International Working Group. Cohen k statistics was used to test the agreement among criteria. RESULTS: Among the 210 participants (mean age 73 years; 38% women), the prevalence of sarcopenia was 28.5%-40.7% in men and 17.5%-32.5% in women. The prevalence of severe sarcopenia was 16.8%-20.0% in men and 11.3%-18.8% in women. The agreement among criteria was poor. The highest agreement was obtained between the European Working Group on Sarcopenia in Older Persons (severe sarcopenia) and International Working Group criteria (k = 0.52 in men; k = 0.65 in women; P < .01 for both). Finally, severe sarcopenia was associated with PD severity (odds ratio 2.30; 95% confidence interval 1.15-4.58). CONCLUSIONS: Sarcopenia is common in PD, with severe sarcopenia being diagnosed in 1 in every 5 patients with PD. We found a significant disagreement among the 3 criteria evaluated, in detecting sarcopenia more than in ruling it out. Finally, sarcopenia is associated with PD severity. Considering its massive prevalence, further studies should address the prognosis of sarcopenia in PD.

The role of cognitive reserve in cognitive aging: what we can learn from Parkinson's disease.

Parkinson's disease (PD) typically occurs in elderly people and some degree of cognitive impairment is usually present. Cognitive reserve (CR) theory was proposed to explain the discrepancy between the degree of brain pathologies and clinical manifestations. We administered a comprehensive neuropsychological battery to 35 non-demented participants affected by PD. All participants underwent also the Cognitive Reserve Index questionnaire and the Brief Intelligence Test as proxies for CR. Relationships between CR and cognitive performance were investigated by linear regression analyses, adjusting for significant confounding factors. At linear regression analyses, higher CR scores were independently associated with a better performance on Word Fluency (p ≤ 0.04) and Digit Span (backward) (p ≤ 0.02); no associations were observed between CR and other cognitive tests. Our data provide empirical support to the relation between CR and cognitive impairment in PD. In particular, this study suggests that CR may have greater effects on the cognitive areas mostly affected in PD as executive functions.

Audiologic Assessment in Adults With Down Syndrome.

Increased life expectancy in persons with Down syndrome (DS) is associated with premature age-related changes. The aim of this study was to assess auditory function in adults with DS and to evaluate the prevalence of hearing loss in this population. Audiometric tests were performed in 72 adults with DS (mean age 37.3±10.1 years, 51.4% females). Air conduction pure tone average (PTA) thresholds at frequencies 0.5-1-2-4 kHz were calculated to assess hearing function. Hearing loss was present if the PTA threshold was > 20 dB hearing level. Higher frequencies of 4 and 8 kHz were also assessed. Hearing loss was shown in 47 (65.3%) participants. The prevalence of hearing loss increased with age, ranging from 42.86% in the 20-29 years group to 90.91% in the 50-59 years group. High frequencies (4 and 8 kHz) were more often impaired than other frequencies used to measure PTA. Thus, the study concluded hearing loss is common in adults with DS and shows a pattern compatible with precocious aging of the hearing system. Auditory evaluation is strongly recommended in adults with DS.

Use of ACE-inhibitors and falls in patients with Parkinson's disease.

Falls represent a major concern in patients with Parkinson's disease (PD); however, currently acknowledged treatments for PD are not effective in reducing the risk of falling. The aim was to assess the association of use of ACE-inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) with falls among patients with PD. We analysed data of 194 elderly with PD attending a geriatric Day Hospital. Self-reported history of falls that occurred over the last year, as well as use of drugs, including ACEIs and angiotensin II receptor blockers (ARBs) were recorded. The association of the occurrence of any falls with use of ACEIs, and ARBs was assessed by logistic regression analysis. The association between the number of falls and use of ACEIs, and ARBs was assessed according to Poisson regression. In logistic regression, after adjusting for potential confounders, use of ACEIs was associated with a reduced probability of falling over the last year (OR=0.15, 95% CI=0.03-0.81; P=0.028). This association did not vary with blood pressure levels (P for the interaction term=0.528). Also, using Poisson regression, use of ACEIs predicted a reduced number of falls among participants who fell (PR=0.31; 95% CI=0.10-0.94; P=0.039). No association was found between use of ARBs and falls. Our results indicate that use of ACEIs might be independently associated with reduced probability, and a reduced number of falls among patients with PD. Dedicated studies are needed to define the single agents and dosages that might most effectively reduce the risk of falling in clinical practice.

Impact of disease duration and cardiovascular dysautonomia on hypertension in Parkinson's disease.

The authors evaluated the association of Parkinson's disease (PD) duration with hypertension, assessed by office measurements and 24-hour (ambulatory) monitoring, in 167 patients. Hypertension was evaluated through both office and ambulatory blood pressure (BP) measurements. Among participants (mean age 73.4±7.6 years; 35% women), the prevalence of hypertension was 60% and 69% according to office and ambulatory BP measurements, respectively (Cohen's k=0.61; P<.001). PD duration was inversely associated with hypertension as diagnosed by office measurements (odds ratio [OR], 0.92; 95% confidence interval [CI], 0.86-0.98) but not by ambulatory monitoring (OR, 0.94; 95% CI, 0.81-1.01). Ambulatory BP patterns showed higher nocturnal BP among patients with long-lasting disease. In conclusion, ambulatory BP monitoring improves the detection of hypertension by 15% in PD, compared with office evaluation. The likelihood of having hypertension does not decrease during the PD course; rather, BP pattern shifts towards nocturnal hypertension.

Physical Restraint and Antipsychotic Medication Use Among Nursing Home Residents With Dementia.

PURPOSE: To explore antipsychotic (AP) medications and physical restraint use and their effects on physical function and cognition in older nursing home residents. METHODS: This retrospective cohort studied involved 532 residents with dementia from 57 nursing homes participating in the Services and Health for Elderly in Long-Term Care study. Poisson log regression models explored the effect of physical restraint and/or AP medication use on cognitive or functional decline at 6 months. RESULTS: Physical restraint use was associated with a higher risk of both functional and cognitive decline compared with AP medication use alone. These risks were highest among residents receiving both AP medications and physical restraints, suggesting additive effects. DISCUSSION: Physical restraint use, and even more strongly, concurrent physical restraint and AP medication use, is related to function and cognitive decline in nursing home residents with dementia. Antipsychotic use is cautioned, but these results suggest physical restraint use is potentially more risky.

Chronic diseases and geriatric syndromes: The different weight of comorbidity.

BACKGROUND: Comorbidity is a relevant health determinant in older adults. Co-occurrence of several diseases and other age-associated conditions generates new clinical phenotypes (geriatric syndromes [GS] as falls, delirium etc.). We investigated the association of chronic diseases, alone or in combination, and GS in older adults receiving home care services in 11 European countries and one Canadian province. METHODS: Participants were cross-sectionally evaluated with the multidimensional assessment instrument RAI HC. We assessed 14 different diagnoses and 8 GS (pain, urinary incontinence, falls, disability, dizziness, weight loss, pressure ulcers and delirium). Adjusted mean number of GS per participant was calculated for groups of participants with each disease when occurring alone or with comorbidity. RESULTS: The mean age of the 6903 participants was 82.2±7.4 years and 4750 (69%) were women. Participants presented with an average of 2.6 diseases and 2.0 GS: pain (48%), urinary incontinence (47%) and falls (33%) were the most prevalent. Parkinson's disease, cerebrovascular disease and peripheral artery disease were associated with the highest number of GS (2.5, 2.3 and 2.2, respectively). Conversely, hypertension, diabetes, dementia, cancer and thyroid dysfunction were associated with the lowest number of GS (2.0 on average). For 9/14 examined diseases (hypertension, diabetes, dementia, COPD, heart failure, ischemic heart disease, atrial fibrillation, cancer and thyroid dysfunction) the number of GS increased with the degree of comorbidity. CONCLUSIONS: Comorbidity and GS are prevalent in older adults receiving home care. Different diseases have a variable impact on occurrence of GS. Comorbidity is not always associated with an increased number of GS.

Anticholinergic drugs and negative outcomes in the older population: from biological plausibility to clinical evidence.

The use of medication with anticholinergic properties is widespread among older subjects. Many drugs of common use such as antispasmodics, bronchodilators, antiarrhythmics, antihistamines, anti-hypertensive drugs, antiparkinson agents, skeletal muscle relaxants, and psychotropic drugs have been demonstrated to have an anticholinergic activity. The most frequent adverse effects are dry mouth, nausea, vomiting, constipation, abdominal pain, urinary retention, blurred vision, tachycardia and neurologic impairment such as confusion, agitation and coma. A growing evidence from experimental studies and clinical observations suggests that drugs with anticholinergic properties can cause physical and mental impairment in the elderly population. However, the morbidity and management issues associated with unwanted anticholinergic activity are underestimated and frequently overlooked. Moreover, their possible relation with specific negative outcome in the elderly population is still not firmly established. The aim of the present review was to evaluate the relationship between the use of drugs with anticholinergic activity and negative outcomes in older persons. We searched PubMed and Cochrane combining the search terms "anticholinergic", "delirium", "cognitive impairment", "falls", "mortality" and "discontinuation". Medicines with anticholinergic properties may increase the risks of functional and cognitive decline, morbidity, institutionalization and mortality in older people. However, such evidences are still not conclusive probably due to possible confounding factors. In particular, more studies are needed to investigate the effects of discontinuation of drug with anticholinergic properties. Overall, minimizing anticholinergic burden should always be encouraged in clinical practice to improve short-term memory, confusion and delirium, quality of life and daily functioning.