Prevalence of aging-associated cognitive decline in an Italian elderly population: results from cross-sectional phase of Italian PRoject on Epidemiology of Alzheimer's disease (IPREA).

BACKGROUND AND AIMS: The prevalence of the preclinical phase of dementia varies greatly, according to the diagnostic criteria and assessment procedures applied. The purpose of this study was to estimate the prevalence of cognitive impairment according to the Aging-Associated Cognitive Decline (AACD) diagnostic criteria in an Italian elderly population. METHODS: In a multicenter community-based prospective study, 4785 Italian subjects aged 65-84 years, randomly selected from the registries of 12 Italian municipalities, were assessed by personal and informant interviews, physical and neurological examinations and an extensive neuropsychological battery. RESULTS: Of these older subjects, 274 (9.2%) fulfilled all the AACD criteria, whereas 561 (18.8%) fulfilled only 3 of them (AACD-3). When the two groups diagnosed according to AACD criteria (AACD and AACD- 3) were merged, the prevalence was 28.0% (28.3% for men, 27.6% for women). Two other groups of subjects were also identified: a) Subjects with Objective evidence of Cognitive Decline without cognitive complaints (OCD), 508 (17.0%), i.e., subjects with documented neuropsychological deficits, although neither subjects nor informants reported cognitive complaints; and b) Subjects with Cognitive Complaints without objective demonstrable cognitive deficits (CC), 44 (1.5%), i.e., subjects and/or informants reported cognitive complaints without evidence of neuropsychological deficits. Thus, taking into account the additional OCD group, a total of 1343 persons with cognitive impairment without dementia (45.0%) was identified. CONCLUSIONS: On the basis of our results, we estimate that 45% of our population-based Italian sample aged 65-84 years had some kind of cognitive deficits without dementia.

Marital and cohabitation status as predictors of mortality: a 10-year follow-up of an Italian elderly cohort.

The relationship between mortality and marital status has long been recognized, but only a small number of investigations consider also the association with cohabitation status. Moreover, age and gender differences have not been sufficiently clarified. In addition, little is known on this matter about the Italian elderly population. The aim of this study is to examine differentials in survival with respect to marital status and cohabitation status in order to evaluate their possible predictive value on mortality of an Italian elderly cohort. This paper employs data from the Italian Longitudinal Study on Aging (ILSA), an extensive epidemiologic project on subjects aged 65-84 years. Of the 5376 individuals followed-up from 1992 to 2002, 1977 died, and 1492 were lost during follow-up period. The baseline interview was administered to 84% of the 5376 individuals and 65% of them underwent biological and instrumental examination. Relative risks of mortality for marital (married vs. non-married) and cohabitation (not living alone vs. living alone) categories are estimated through hazard ratios (HR), obtained by means of the Cox proportional hazards regression model, adjusting for age and several other potentially confounding variables. Non-married men (HR=1.25; 95% CI: 1.03-1.52) and those living alone (HR=1.42; 95% CI: 1.05-1.92) show a statistically significant increased mortality risk compared to their married or cohabiting counterparts. After age-adjustment, women's survival is influenced neither by marital status nor by cohabitation status. None of the other covariates significantly alters the observed differences in mortality, in either gender. Neither marital nor cohabitation status are independent predictors of mortality among Italian women 65+, while among men living alone is a predictor of mortality even stronger than not being married. These results suggest that Italian men benefit more than women from the protective effect of living with someone.

Health observation compared to health reporting: findings from a pilot study in Florence.

PURPOSE: Both health interview surveys (HISs) and health examination surveys (HESs) are used to describe the health status of populations. In Italy, to determine the feasibility of conducting a national-level HES, a pilot HES was conducted in the city of Florence among participants of a previous national-level HIS. The aim of the present analysis was to compare the results of the two surveys. METHODS: The study population consisted of the 343 Florence residents 35 to 74 years of age who participated in both surveys (sample drawn with probabilistic criteria). We compared the self-reported HIS data to the HES health measurements for diabetes, hypertension, osteoporosis, smoking, height, weight, and body mass index. For categorical variables, contingency tables were used, calculating symmetric and asymmetric indices. For the continuous variables, Student's t test for matched samples was used. RESULTS: The prevalence of the most important pathologic conditions and risk factors determined with HES measurements was significantly higher than that based on self-reported HIS data. CONCLUSIONS: The results stress that individuals have poor knowledge of their own health; therefore health measurements need to be taken.

Impaired attention predicts motor performance decline in older community-dwellers with normal baseline mobility: results from the Italian Longitudinal Study on Aging (ILSA).

BACKGROUND: Cognitive decline, particularly when executive functions are compromised, may worsen motor performance (MP) decline in the elderly population. We investigated whether a global test, a memory test, and an attention test predicted MP decline in older community-dwellers with normal baseline MP participating in the Italian Longitudinal Study on Aging (ILSA). METHODS: One thousand fifty-two ILSA participants (71.2 +/- 4.8 years old, mean +/- standard deviation [SD], 67% men), with normal baseline MP were reassessed after 3 years using the same MP battery. Participants whose MP score reduction from baseline to follow-up was > 75 percentile were considered to be MP decliners. Global cognition, memory, and attention were assessed using the Mini-Mental State Examination (MMSE), the Babcock Story Recall Test (BSRT), and the Digit Cancellation Test (DCT), respectively. The baseline score on each test was examined as a potential predictor of decline in global MP or in single motor tasks. RESULTS: Baseline scores on the three cognitive tests were worse among the 166 MP decliners, compared with nondecliners. Participants in the lowest quartile of DCT had a > 2-fold higher adjusted risk of declining than did participants in the highest quartile (odds ratio = 2.47, 95% confidence interval, 1.29-4.74). Conversely, MMSE and BSRT scores no longer predicted MP decline after adjustment. Impaired attention strongly predicted the decline in attention-demanding tasks (tandem walking), but also affected routine tasks (walking). CONCLUSIONS: Impairment in a test measuring attention predicts MP decline among older community-dwellers with normal baseline MP. This finding is consistent with the hypothesis that attentional and executive dysfunction is a major determinant of mobility disability in elderly persons.

Risk and predictors of motor-performance decline in a normally functioning population-based sample of elderly subjects: the Italian Longitudinal Study on Aging.

OBJECTIVES: To examine risk and predictors of motor-performance (MP) decline targeting subjects performing normally at an initial observation. DESIGN: Cohort study. SETTING: A subsample of the Italian Longitudinal Study on Aging (aged 65-84). PARTICIPANTS: One thousand fifty-two subjects (mean age+/-standard deviation = 71+/-5, 69% men) with normal MP at baseline. MEASUREMENTS: Six tests (standing up from a chair, stepping up, tandem walk, standing on one leg, walking speed, and steps turning 180 degrees ) were used to assess MP at baseline and after 3 years. Baseline characteristics were potential predictors of MP decline. RESULTS: Of the 1,052 subjects performing normally at baseline, 166 (15.8%) had declined in MP at follow-up. Older age, female sex, lower education, symptoms of distal symmetrical neuropathy, cognitive impairment without dementia, parkinsonism, heart failure, anemia, depressive symptoms, worse Mini-Mental State Examination score, and lost activities of daily living and instrumental activities of daily living (IADLs) were significantly associated with MP decline in univariate comparisons. Older age (odds ratio (OR) = 3.84, 95% confidence interval (CI) = 2.14-6.88 comparing age classes > or =80 with 65-69), female sex (OR=1.50, 95% CI = 1.03-2.20), distal symmetric neuropathy (OR = 2.00, 95% CI = 1.03-3.87), depressive symptoms (OR = 1.85, 95% CI = 1.17-2.24), and baseline IADLs (OR = 1.22, 95% CI = 1.08-1.37 for each lost activity) independently predicted MP decline after regression analysis. CONCLUSION: In a population-based cohort of elderly people with normal MP, one-sixth declined in 3 years. Age, sex, distal symmetrical neuropathy, depressive symptoms, and baseline IADLs independently predicted this decline. Distal symmetrical neuropathy is underestimated in the clinical and epidemiological evaluation of motor decline in older people.

Italian Project on Epidemiology of Alzheimer's disease (I.PR.E.A.): study design and methodology of cross-sectional survey.

BACKGROUND AND AIMS: The purpose of this paper is to describe the design and diagnostic procedures of the multicenter community-based prospective Italian Project on the Epidemiology of Alzheimer's disease (I.PR.E.A.). The study is aimed at estimating the prevalence and incidence of Alzheimer's disease (AD) in the preclinical phase, examining the natural history of cognitive decline without dementia (mainly AD) in the Italian population, and identifying risk factors or health determinants related or associated with various health outcomes. METHODS: Both cross-sectional and longitudinal phases will be performed in 4800 elderly subjects aged 65-84 years. The sample will be selected from the registries of 12 Italian rural and urban municipalities, with an interval of one year between examinations. The study population will undergo several screening examinations, including personal and informant interviews by means of a structured ad hoc questionnaire, physical and neurological examination, laboratory tests, genetic markers and a neuropsychological battery. Neuroimaging screening will also be carried out in a subgroup of subjects positive for cognitive impairment without dementia. The longitudinal phase will include all subjects who, during the cross-sectional survey, are identified as affected by cognitive impairment without dementia, and will aim at assessing the incidence and natural history of cognitive impairment without dementia and the degree of disease progression from the earliest stage. This is the first systematic prospective study on the preclinical phase of AD in Italy.

Depressive symptoms and development of coronary heart disease events: the Italian longitudinal study on aging.

BACKGROUND: Studies on the association between depressive symptomatology (DS) and cardiovascular events and mortality in elderly persons have yielded contradictory findings. To address this issue, the authors assessed DS and an extensive array of sociodemographic, behavioral, and biological variables in the largest population-based sample of older Italians ever studied and analyzed their association with coronary heart disease (CHD) morbidity and total number of deaths. METHODS: This prospective, community-based cohort study included a sample of 5632 Italians, 65 years and older, who were recruited from the demographic registries of eight municipalities in Italy. Depressive symptomatology was assessed using the Geriatric Depression Scale, and a score > or =10 was used to indicate the presence of DS. All traditional cardiovascular disease risk factors were assessed at baseline, through questionnaires, blood tests, and physical examinations. The outcomes were CHD fatal and nonfatal events and total number of deaths. The association of the predictive variables with the outcomes was assessed using different Cox models. RESULTS: Baseline DS was associated with a higher incidence of fatal and nonfatal CHD events (hazard ratio [HR], 1.66; 95% confidence interval [CI], 1.06-2.60) and with cardiovascular mortality in men (HR, 2.49; 95% CI, 1.60-3.87) and with total mortality in men (HR, 2.02; 95% CI, 1.58-2.58) and women (HR, 1.43; 95% CI, 1.04-1.95) at the 4-year follow-up assessment. This association was observed after adjusting for a vast array of potential confounding variables, including major chronic conditions. CONCLUSIONS: Depressive symptomatology confers an increased risk for CHD in men and for total mortality in men and women but is not explained by health behaviors, social isolation, or biological or clinical determinants.

An index to measure the association between dietary patterns and coronary heart disease risk factors: findings from two Italian studies.

BACKGROUND: To examine the association between established coronary heart disease (CHD) risk factors and eating patterns by creating a dietary index utilizing a limited amount of food frequency questionnaire data on specified indicator foods. METHODS: Selected data from the Italian Risk Factors and Life Expectancy (RIFLE) project collected between 1978-1979 and 1983-1984 on 7665 men and women, aged 20-59 years, were used to compute a dietary index summarizing the relative proportion of fatty to non-fatty foods. The association between this index and systolic and diastolic blood pressure (SBP, DBP), body mass index, total serum cholesterol (TC), and blood glucose, controlling for potential confounders was then tested using multiple linear regression. RESULTS: Among men, a positive association was found between the index and all five CHD risk factors (P < 0.01). Among women, the associations were weaker, becoming statistically significant only for TC and glucose. CONCLUSIONS: Our food index was able to detect relationships between diet and traditional CHD risk factors. A tool such as this, which requires only a limited number of key indicator food items, might enhance the use of existing food frequency questionnaires and also streamline the process of collecting new dietary information.

Risk factors and health determinants in older Italians.

BACKGROUND AND AIMS: According to a WHO estimate, 50% of the total burden of diseases in men and 25% in women for the EURO-A group (which includes the highly developed countries of the WHO European Region) are attributable to unhealthy life-styles. The aim of the present study was to analyze anthropometric, biochemical and behavioral risk factors using data from the Italian Longitudinal Study on Aging (ILSA), a population-based study of older Italians initiated in 1992 to study those chronic conditions and attendant risk factors that contribute most substantially to morbidity, disability and mortality. METHODS: In this descriptive study, we calculated the means and distribution of risk factors in a sample of 5632 Italian subjects aged 65-84 by gender, age class and geographic area, and identified the proportion of these subgroups at higher risk. Analyses include data from the first (1992-93) and second (1995-96) examinations of this cohort. RESULTS: Over 64% of older Italian participants were overweight in 1992. More than 70% had blood pressure in the borderline or definitely hypertensive range, and almost one-third had hyperlipidemic serum cholesterol levels, including subjects receiving treatment for these conditions. Based on Body Mass Index, more women than men were obese (27 vs 15%) and more women than men were hyperlipidemic in all age classes (38 vs 23%). Approximately 13% of the sample had glucose levels exceeding the recommended 126 mg/dL. Men were found to consume on average about 41 grams of alcohol daily and women 17 g/d. Lastly, we found that approximately 20% of men and 8% of women were smokers in 1992 but that smoking tended to diminish with age. CONCLUSIONS: As the Italian population rapidly ages, the burden of disease and disability is increasing, necessitating more focused, immediate and effective prevention programs. We have identified a number of critical concerns ripe for intervention. The results of this study can better focus such efforts and help guide long-term health planning and policy.

Vegetable intake and long-term survival among middle-aged men in Italy.

PURPOSE: To examine prospectively the relationship between vegetable consumption and long-term survival. METHODS: In 1965, a total of 1536 Italian males from two Italian rural cohorts of the Seven Countries Study, aged 45-65 years, were examined. Information on lifestyle and food consumption collected at this visit, and total and cause-specific mortality data collected in 30 years of follow-up were analyzed for the present study. RESULTS: During a period of 30 years, 1096 deaths occurred (308 from coronary heart disease, 325 from cancer, 158 from cerebrovascular disease and 305 from all other causes). The age-adjusted life expectancy for men consuming more than 60 g/day of vegetables was nearly 2 years longer than for men consuming less than 20 g/day. This increase in survival was more striking in smokers than nonsmokers (2.1 vs. a 1 year gain). The association also held for both geographic cohorts, although the pattern of vegetable consumption was very different in the two villages. CONCLUSIONS: The results suggest a positive association between vegetable intake and life expectancy. Vegetable intake may be especially protective for smokers although the biological explanation for such an effect is unclear.

Low total cholesterol and increased risk of dying: are low levels clinical warning signs in the elderly? Results from the Italian Longitudinal Study on Aging.

OBJECTIVES: To analyze the relationship between serum total cholesterol (TC) and all-cause mortality, taking into account various potential confounders. DESIGN: Population-based prospective cohort study. SETTING: Older Italians residing in the general community. PARTICIPANTS: Four thousand five hundred twenty-one men and women aged 65-84. MEASUREMENTS: Vital status data were available for 1992-95. The hazard ratios of dying for subjects in the second, third, and fourth quartiles compared with the first quartile of TC were computed using Cox proportional hazards, adjusting for lifestyle factors, anthropomorphic and biochemical measures, preexisting medical conditions, and frailty indicators. RESULTS: Blood samples were obtained from 3,295 (73%) of the participants, of whom 399 died during almost 3 years of follow-up. Low TC was associated with a higher risk of death. Those with TC in the second, third, and fourth quartiles (TC>189 mg/dL or 4.90 mmol/L) had lower hazard ratios (HRs) of death than subjects in the first quartile (0.57, 95% confidence interval (CI) = 0.38-0.87; 0.56, 95% CI = 0.36-0.88; and 0.53, 95% CI = 0.33-0.84, respectively). Few subjects taking lipid-lowering drugs (LLDs) were in the lowest quartile of cholesterol, suggesting that these individuals have low TC values for reasons other than LLD use. CONCLUSION: Subjects with low TC levels (<189 mg/dL) are at higher risk of dying even when many related factors have been taken into account. Although more data are needed to clarify the association between TC and all-cause mortality in older individuals, physicians may want to regard very low levels of cholesterol as potential warning signs of occult disease or as signals of rapidly declining health.

Incidence of dementia, Alzheimer's disease, and vascular dementia in Italy. The ILSA Study.

OBJECTIVES: To estimate the incidence of dementia, Alzheimer's disease (AD), and vascular dementia (VaD) in older Italians and evaluate the relationship of age, gender, and education to developing dementia. DESIGN: Cohort incidence study in the context of the Italian Longitudinal Study on Aging. SETTING: Population sample from eight Italian municipalities. PARTICIPANTS: A dementia-free cohort of 3,208 individuals (aged 65-84), individuated after a baseline evaluation performed in 1992 / 93, aimed at detecting prevalent cases. MEASUREMENTS: The dementia-free cohort was reexamined in 1995 to identify incident cases. The Mini-Mental State Examination (cutoff 23 / 24) was employed to screen for dementia. Trained neurologists evaluated the individuals who screened positive. Final diagnoses had to meet Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised criteria for dementia, National Institute of Neurological and Communicative Disorders and Stroke-Alzheimer's Disease and Related Disorders Association criteria for AD, and International Classification of Diseases, Tenth Revision criteria for VaD. RESULTS: Before the follow-up examination, 382 individuals had died (232 had reliable information). Of the 2,826 survivors, 2,266 completed the study. Overall, 127 new dementia cases were identified. Average incidence rates per 1,000 person-years were 12.47 (95% confidence interval (CI)=10.23-14.72) for dementia, 6.55 (95% CI=4.92-8.17) for AD, and 3.30 (95% CI=2.14-4.45) for VaD. Both AD and VaD showed age-dependent patterns. Education was protective against dementia and AD. Women carried a significantly higher risk of developing AD (hazard ratio=1.67, 95% CI=1.02-2.75), and men of developing VaD (hazard ratio=2.23, 95% CI=1.06-4.71). CONCLUSIONS: Incidence of dementia in Italy paralleled that in most industrialized countries. About 150,000 new cases per year are expected. A significant gender effect was evidenced for major dementia subtypes. The burden of VaD, especially in men, offers opportunities for prevention.