Cardiovascular risk profiling of long-lived people shows peculiar associations with mortality compared with younger individuals.

AIM: Centenarians represent a biological model of successful aging because they escaped/postponed most invalidating age-related diseases, such as cardiovascular diseases. The aim of the present study was to clarify whether a favorable cardiovascular risk profile increases the survival chances in long-lived people. METHODS: A total of 355 community-dwelling nonagenarians and centenarians living in Southern Italy were recruited in the study. Patients were classified as at low and high cardiovascular risk on the basis of serum cholesterol, diabetes, hypertension and smoking status. The relationship between cardiovascular risk factors and 10-year mortality was investigated by Cox regression analysis. Splines-based hazard ratio curves were also estimated for total cholesterol, low-density lipoprotein cholesterol, and systolic and diastolic blood pressure. RESULTS: Low levels of selected cardiovascular risk factors usually associated with lower mortality in adults do not increase survival chances among oldest-old individuals. In particular, after adjusting for age, sex, and cognitive, functional and nutritional status, serum cholesterol >200 mg/dL increased the survival chances during the follow-up period (hazard ratio 0.742, 95% CI 0.572-0.963). CONCLUSIONS: The present results showed that in nonagenarians and centenarians, the clinical and prognostic meaning associated with traditional cardiovascular risk factors is very different from younger populations. Consequently, considering the increase of this population segment, further studies are required to confirm these results and to translate them into clinical practice/primary care. Geriatr Gerontol Int 2019; 19: 165-170.

Methylation of the ribosomal RNA gene promoter is associated with aging and age-related decline.

The transcription of ribosomal RNA genes (rDNA) is subject to epigenetic regulation, as it is abrogated by the methylation of CpG dinucleotides within their promoter region. Here, we investigated, through Sequenom platform, the age-related methylation status of the CpG island falling into the rDNA promoter in 472 blood samples from 20- to 105-year-old humans and in different tissues (blood, heart, liver, kidney, and testis) of 15 rats 3-96 weeks old. In humans, we did not find a consistently significant correlation between CpG site methylation and chronological age. Furthermore, the methylation levels of one of the analyzed CpG sites were negatively associated with both cognitive performance and survival chance measured in a 9-year follow-up study. We consistently confirmed such result in a replication sample. In rats, the analysis of the homologous region in the tissues revealed the existence of increased methylation in old rats. rRNA expression data, in both humans and rats, were consistent with observed methylation patterns, with a lower expression of rRNA in highly methylated samples. As chronological and biological ages in rats of a given strain are likely to be much closer to each other than in humans, these results seem to provide the first evidence that epigenetic modifications of rDNA change over time according to the aging decline. Thus, the methylation profile of rDNA may represent a potential biomarker of aging.

Medication-Induced Nephrotoxicity in Older Patients.

OBJECTIVE: To summarize current evidence about mechanisms, clinical features, diagnostic issues, and strategies for prevention of medication-induced nephrotoxicity among older people. METHODS: A Pubmed search was performed, and studies concerning age-related changes in kidney structure and function predisposing to nephrotoxicity, pathophysiological mechanisms, kidney drug metabolism enzymes, clinical epidemiology of medication-induced kidney damage, biomarkers for early identification of nephrotoxicity and strategies for prevention of medication-induced nephrotoxicity among older people were selected. Finally, 245 papers were included in the review. RESULTS: Medications may induce nephrotoxicity through several pathophysiological mechanisms. People aged 75 or more are especially exposed to potential nephrotoxic medications or combinations of medications in the context of complex polypharmacy regimens. Estimated glomerular filtration rate (eGFR) may be useful to identify medication-induced alterations in kidney function, but creatinine-based methods have important limitation in older patients. Several innovative biomarkers have been proposed to identify AKI but these methodologies are not standardized and older people have not been evaluated systematically. Factors related to patient, medication, and interactions should be taken into account for effective prevention. CONCLUSIONS: Medication-induced nephrotoxicity is a relevant problem in older populations. Nevertheless, several areas of uncertainty remain to be explored, including the impact of nephrotoxicity on functional outcomes relevant to older patients, the reliability of currently recommended methods for diagnosing and staging AKI, the use of innovative biomarkers in such a heterogeneous population, the effectiveness of preventing strategies and treatments and their impact on functional outcomes.

Estimating glomerular filtration rate in older people.

We aimed at reviewing age-related changes in kidney structure and function, methods for estimating kidney function, and impact of reduced kidney function on geriatric outcomes, as well as the reliability and applicability of equations for estimating glomerular filtration rate (eGFR) in older patients. CKD is associated with different comorbidities and adverse outcomes such as disability and premature death in older populations. Creatinine clearance and other methods for estimating kidney function are not easy to apply in older subjects. Thus, an accurate and reliable method for calculating eGFR would be highly desirable for early detection and management of CKD in this vulnerable population. Equations based on serum creatinine, age, race, and gender have been widely used. However, these equations have their own limitations, and no equation seems better than the other ones in older people. New equations specifically developed for use in older populations, especially those based on serum cystatin C, hold promises. However, further studies are needed to definitely accept them as the reference method to estimate kidney function in older patients in the clinical setting.

Glomerular filtration rate in the elderly and in the oldest old: correlation with frailty and mortality.

The equations for estimating kidney function have become very popular in the last decade. However, the clinical and prognostic meaning of these measures may be very different in older populations. Two cohorts of people aged 65-89 years (older sample) and 90 or more (oldest old sample) were used to investigate the prognostic significance of estimated glomerular filtration rate (eGFR). Additionally, we also investigated whether combining frailty and eGFR may improve the accuracy of frailty in predicting mortality. We found that lower eGFR values were significantly more frequent among frail subjects in both groups. eGFR < 30 was associated with increased risk for all-cause mortality either in subjects aged 65-89 years (HR = 3.71, 95% CI = 1.23-11.2) or in those aged 90 or more (HR = 1.53, 95% CI = 1.05-2.23). In the latter group, a not significant trend for increasing mortality was also observed among people with eGFR > 60 (HR = 1.28, 95% CI = 0.72-2.26). In addition, the oldest old subjects with eGFR > 60 and eGFR < 30 had the lowest hand-grip strength and ADL values. Combining eGFR and frailty status significantly improved the accuracy of frailty in predicting mortality only in the older sample. In conclusion, a U-shaped relationship exists between eGFR and mortality in the oldest old, but not in older individuals. Our findings suggest that eGFR needs to be adjusted for muscle mass/physical performance when estimating kidney function in people aged 90 or more. Nevertheless, in subjects aged 65-89 years, eGFR may improve the accuracy of frailty status in predicting prognosis, thus suggesting that eGFR may represent an additional dimension of frailty syndrome.

How to classify the oldest old according to their health status: a study on 1160 subjects belonging to 552 90+ Italian sib-ships characterized by familial longevity recruited within the GEHA EU Project.

The health status of the oldest old, the fastest increasing population segment worldwide, progressively becomes more heterogeneous, and this peculiarity represents a major obstacle to their classification. We compared the effectiveness of four previously proposed criteria (Franceschi et al., 2000; Evert et al., 2003; Gondo et al., 2006; Andersen-Ranberg et al., 2001) in 1160 phenotypically fully characterized Italian siblings of 90 years of age and older (90+, mean age: 93 years; age range: 90-106 years) belonging to 552 sib-ships, recruited in Northern, Central and Southern Italy within the EU-funded project GEHA, followed for a six-year-survival. Main findings were: (i) "healthy" subjects varied within a large range, i.e. 5.2% (Gondo), 8.7% (Evert), 17.7% (Franceschi), and 28.5% (Andersen-Ranberg); (ii) Central Italy subjects showed better health than those from Northern and Southern Italy; (iii) mortality risk was correlated with health status independently of geographical areas; and (iv) 90+ males, although fewer in number, were healthier than females, but with no survival advantage. In conclusion, we identified a modified version of Andersen-Ranberg criteria, based on the concomitant assessment of two basic domains (cognitive, SMMSE; physical, ADL), called "Simple Model of Functional Status" (SMFS), as the most effective proxy to distinguish healthy from not-healthy subjects. This model showed that health status was correlated within sib-ships, suggesting a familial/genetic component.

Common polymorphisms in nitric oxide synthase (NOS) genes influence quality of aging and longevity in humans.

Nitric oxide (NO) triggers multiple signal transduction pathways and contributes to the control of numerous cellular functions. Previous studies have shown in model organisms that the alteration of NO production has important effects on aging and lifespan. We studied in a large sample (763 subjects, age range 19-107 years) the variability of the three human genes (NOS1, -2, -3) coding for the three isoforms of the NADPH-dependent enzymes named NO synthases (NOS) which are responsible of NO synthesis. We have then verified if the variability of these genes is associated with longevity, and with a number of geriatric parameters. We found that gene variation of NOS1 and NOS2 was associated with longevity. In addition NOS1 rs1879417 was also found to be associated with a lower cognitive performance, while NOS2 rs2297518 polymorphism showed to be associated with physical performance. Moreover, SNPs in the NOS1 and NOS3 genes were respectively associated with the presence of depression symptoms and disability, two of the main factors affecting quality of life in older individuals. On the whole, our study shows that genetic variability of NOS genes has an effect on common age related phenotypes and longevity in humans as well as previously reported for model organisms.

Urinary incontinence in the elderly and in the oldest old: correlation with frailty and mortality.

Urinary incontinence (UI) is very common in the elderly and has personal and social implications. Many authors have pointed out the necessity to analyze UI in correlation with the overall quality of aging, to better understand this syndrome and define measures for its prevention and treatment. In the present study, we addressed this problem by analyzing the UI correlation with frailty, which has emerged in the last decade as the geriatric syndrome correlated with individual homeostatic capacity and then as the basis of the age-related physical decline. In addition, the monitoring of our sample for a long period allowed us to estimate the prognostic significance of UI by analyzing the correlation between UI and mortality. The analysis was performed in a large sample that included numerous ultra-nonagenarians, a population segment that is still poorly known for UI and other geriatric parameters. We found a strict correlation between UI and frailty, suggesting that UI is correlated to the homeostatic and physiological decline leading to frailty. In addition, we found that UI is an independent mortality risk factor in ultra-nonagenarians, suggesting that the neurological sensitivity needed to be continent is lost very soon when the frailty associated physiological decline begins. On the whole, our study suggests that UI is a marker of frailty and that UI patients should be monitored and, in case, treated in a timely manner to avoid, or to limit, the effects of frailty such as malnutrition, falls, and the consequent accumulation of disabilities.

Global DNA methylation in old subjects is correlated with frailty.

Epigenetic variations have been widely described to occur during the aging process. To verify if these modifications are correlated with the inter-individual phenotypic variability of elderly people, we searched for a correlation between global DNA methylation levels and frailty. We found that the global DNA methylation levels were correlated to the frailty status in middle/advanced-aged subjects but not with age. A 7-year follow-up study also revealed that a worsening in the frailty status was associated to a significant decrease in the global DNA methylation levels. These results suggest that the relaxation of the epigenetic control in aging is specifically associated with the functional decline rather than with the chronological age of individuals. Thus, the modifications of DNA methylation, representing a drawbridge between the genetic and the environmental factors affecting the age-related decay of the organism, may play an important role in determining physiological changes over old age.

Chronic kidney disease and 1-year survival in elderly patients discharged from acute care hospitals: a comparison of three glomerular filtration rate equations.

BACKGROUND: Glomerular filtration rate (GFR) is directly associated with survival. However, the prognostic significance of GFR might be different according to the formula used to estimate it. We aimed at comparing the association between GFR estimated using three different formulas and 1-year survival in elderly patients discharged from acute care hospitals. METHODS: Our series consisted of 439 patients aged 65 and older admitted to 11 acute care medical wards enrolled in a multicentre prospective observational study. GFR was estimated by body surface area-adjusted Cockcroft-Gault (CG-BSA), Modification of Diet in Renal Disease study (MDRD) and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formulas. The relative risk of mortality in patients with estimated GFR = 30-59.9 or < 30 mL/min/1.73 m(2) compared to people with estimated GFR ≥ 60 mL/min/1.73 m(2) was calculated using Cox regression analysis. RESULTS: Participants with reduced GFR showed an increased mortality, regardless of the equation used, and the highest one was associated with CG-BSA-estimated GFR < 30 mL/min/1.73 m(2). After adjusting for potential confounders, CKD-EPI-estimated GFR remained significantly associated with the outcome [30-59.9 mL/min/1.73 m(2), hazard ratio (HR) = 1.70, 95% confidence interval (95% CI) = 1.02-2.98; < 30 mL/min/1.73 m(2), HR = 2.60, 95% CI = 1.20-5.66], while the strength of the association was clearly reduced for MDRD (30-59.9 mL/min/1.73 m(2), HR = 1.47, 95% CI = 0.83-2.38; < 30 mL/min/1.73 m(2), HR = 2.07, 95% CI = 1.01-4.30) and CG-BSA (30-59.9 mL/min/1.73 m(2), HR = 1.79, 95% CI = 0.67-4.53; < 30 mL/min/1.73 m(2), HR = 2.68, 95% CI = 0.92-7.55). CONCLUSION: GFR adds to the list of prognostic indicators in elderly and frail people, and CKD-EPI-derived GFR, which outperforms to some extent MDRD and CG-BSA-derived GFR in a multivariable predictive model, seems worthy of testing in wider populations.

To grow old in southern Italy: a comprehensive description of the old and oldest old in Calabria.

BACKGROUND: The unprecedented growth of the elderly population is posing important social and medical problems as management of this population is highly demanding in terms of assistance and care. Consequently, many studies are focusing on the elderly subjects in order to better understand their needs by identifying various environmental, social, psychological, and genetic factors determining the quality of ageing. OBJECTIVES: Our aim was to carry out a survey of the elderly Calabrian population in order to highlight the social and medical conditions of this continuously growing population group. METHODS: We have been monitoring the elderly population of Calabria for more than 10 years. For the present study, we collected data regarding 853 subjects by using two specific questionnaires, one for the subjects older than 90 years (400 subjects) and one for the subjects aged between 65 and 85 years (453 subjects). RESULTS: The survey allowed us to carry out an extensive description of the ageing Calabrian population regarding the sociodemographic characteristics, living conditions, cognitive functioning, level of independence in activities of daily living, former and current diseases and health disorders. We could notice that males were in a better condition than females. In fact, male subjects turned out to have better physical performance and lower comorbidity, although their life expectancy is lower. Ultranonagenarians had a lower incidence of serious diseases (such as diabetes, osteoporosis and gastric ulcer), but a higher incidence of non-fatal chronic, debilitating conditions (cataract and bronchitis among others). CONCLUSION: The data we collected and analyzed offer a portrait of elderly Calabrian subjects, on who they are, how they feel, which social and psychological resources they have, and what their health status is. Analysis of the data highlighted that they are characterized by a lower physical performance in comparison to other European populations. Finally, the data presented here may also serve as a valuable source of information to characterize the ageing Calabrian population and improve the care of these subjects.

Does concealed chronic kidney disease predict survival of older patients discharged from acute care hospitals?

We aimed at verifying whether unrecognized chronic kidney disease (CKD) (i.e., reduced estimated glomerular filtration rate in spite of normal serum creatinine) has prognostic significance in an unselected population of older patients discharged from 11 acute care hospitals located throughout Italy. Our series consisted of 396 participants aged 70 and older. Estimated glomerular filtration rate (eGFR) was calculated by the Modification of Diet in Renal Disease (MDRD) study equation. We compared three groups: Normal renal function (normal serum creatinine levels and normal eGFR), concealed (normal serum creatinine levels and reduced eGFR), or overt (increased creatinine levels and reduced eGFR) renal failure. The relationship between renal function and 1-year mortality was evaluated using Kaplan-Meier curves and Cox regression analysis including potential confounders. Overall, 56 patients died over a cumulative follow-up time of 335 months, with an estimated incidence rate of 16.7/100 person-year (PY). The corresponding figures in patients with normal renal function, concealed CKD, and overt CKD were 9.8/100 PY (95% CI, 5.7-15.7), 28.3/100 PY (95% CI, 13.6-52.1), and 23.0 (95% CI, 15.4-33.0), respectively (log rank test p = 0.006). According to the fully adjusted model, both concealed (hazard ratio [HR], 2.35; 95% CI, 1.09-6.01) and overt CKD (HR, 2.09; 95% CI, 1.05-5.34) were significantly associated with the outcome. Concealed CKD contributes to profile the elderly patient at greater risk of death after being discharged from acute care medical wards. If confirmed in broader populations, this finding might have both clinical and epidemiological implications.

A cross-section analysis of FT3 age-related changes in a group of old and oldest-old subjects, including centenarians' relatives, shows that a down-regulated thyroid function has a familial component and is related to longevity.

BACKGROUND: several studies suggest that a decreased thyroid activity might be favourable in oldest-old subjects and that subclinical thyroid hyperfunction may be detrimental. OBJECTIVES: to verify whether declining levels of circulating thyroid hormones may contribute to longevity. DESIGN: cross-sectional observational study. SETTING: all subjects were born in Calabria (southern Italy) and their ancestry in the region was ascertained up to the grandparents. SUBJECTS: six hundred and four home-dwelling subjects (301 females, 303 males), divided into three groups: 278 individuals 60-85 years old; 179 children or nieces/nephews of centenarians who are 60-85 years old; 147 individuals older than 85 years. METHODS: thyroid function parameters were measured in the frame of a comprehensive geriatric assessment. RESULTS: FT3 and FT4 levels were negatively associated with age. Lower levels of FT3, FT4 and TSH were found in centenarians' children and nieces/nephews with respect to age-matched controls. Indeed, being a relative of centenarians qualified as an independent correlate of thyroid parameters. CONCLUSIONS: age-related subtle thyroid hypofunction (either due to a familial component or due to a reset of the thyroid function occurring between the sixth and the eighth decade of life) appears to be related to longevity.

A novel, population-specific approach to define frailty.

The description of frailty, a syndrome of the elderly due to the decline of homeostatic capacities, has opened new opportunities in the study of the biological basis of human aging. However, the noticeable heterogeneity for this trait in different geographic areas makes it difficult to use standardized methods for measuring the quality of aging in different populations. Consequently, the necessity to carry out population-specific surveys to define tools which are able to highlight groups of subjects with homogeneous aging phenotype within each population has emerged. We carried out an extensive monitoring of the status of the elderly population in Calabria, southern Italy, performing a geriatric multidimensional evaluation of 680 subjects (age range 65-108 years). Then, in order to classify the subjects, we applied a cluster analysis which considered physical, cognitive, and psychological parameters such as classification variables. We identified groups of subjects homogeneous for the aging phenotypes. The diagnostic and predictive soundness of our classification was confirmed by a 3-year longitudinal study. In fact, both Kaplan-Meier estimates of the survival functions and Cox proportional hazard models indicate higher survival chance for subjects characterized by lower frailty. The availability of operative frailty phenotypes allows a reappraisal of the biological basis of healthy aging as it regards both biomarkers correlated with the frail phenotype and the genetic variability associated with the phenotypes identified. Indeed, we found that the frailty phenotype is strongly correlated with clinical parameters associated with the nutritional status.

APOE polymorphism affects episodic memory among non demented elderly subjects.

The APOE epsilon4 allele has been associated with a number of neurodegenerative disorders e.g. Alzheimer's disease. Inconsistent results have been obtained for cognitive decline in 'normal' aging. We investigated whether specific aspects of cognitive decline were associated with APOE epsilon4 among 620 'healthy' elderly subjects living in Calabria, southern Italy. MMSE scores ranged from 11 to 30. A lower MMSE score was unrelated to APOE polymorphism, i.e. a global measure of cognition. However, poorer episodic memory was associated with APOE epsilon4, both registration (p=0.01) and recall (p=0.01). Temporal and spatial orientation, attention and calculation, language, and constructive function were not affected. We conclude that episodic memory, specifically, is adversely affected by APOE epsilon4 and urge evaluation of precise phenotypes in genetic association studies of cognitive decline in order to avoid inconsistent results due to phenotypic heterogeneity.

A novel sampling design to explore gene-longevity associations: the ECHA study.

To investigate the genetic contribution to familial similarity in longevity, we set up a novel experimental design where cousin-pairs born from siblings who were concordant or discordant for the longevity trait were analyzed. To check this design, two chromosomal regions already known to encompass longevity-related genes were examined: 6p21.3 (genes TNFalpha, TNFbeta, HSP70.1) and 11p15.5 (genes SIRT3, HRAS1, IGF2, INS, TH). Population pools of 1.6, 2.3 and 2.0 million inhabitants were screened, respectively, in Denmark, France and Italy to identify families matching the design requirements. A total of 234 trios composed by one centenarian, his/her child and a child of his/her concordant or discordant sib were collected. By using population-specific allele frequencies, we reconstructed haplotype phase and estimated the likelihood of Identical By Descent (IBD) haplotype sharing in cousin-pairs born from concordant and discordant siblings. In addition, we analyzed haplotype transmission from centenarians to offspring, and a statistically significant Transmission Ratio Distortion (TRD) was observed for both chromosomal regions in the discordant families (P=0.007 for 6p21.3 and P=0.015 for 11p15.5). In concordant families, a marginally significant TRD was observed at 6p21.3 only (P=0.06). Although no significant difference emerged between the two groups of cousin-pairs, our study gave new insights on the hindrances to recruiting a suitable sample to obtain significant IBD data on longevity-related chromosomal regions. This will allow to dimension future sampling campaigns to study-genetic basis of human longevity.

The mitochondrial DNA control region shows genetically correlated levels of heteroplasmy in leukocytes of centenarians and their offspring.

BACKGROUND: Studies on heteroplasmy occurring in the mitochondrial DNA (mtDNA) control region (CR) in leukocytes of centenarians and younger subjects have shown that the C150T somatic transition is over-represented in centenarians. However, whether the occurrence/accumulation of heteroplasmy is a phenotypic consequence of extreme ageing or a genetically controlled event that may favor longevity is a question that deserves further attention. To clarify this point, we set up a Denaturing High Performance Liquid Chromatography (DHPLC) protocol to quantify mtDNA CR heteroplasmy. We then analyzed heteroplasmy in leukocytes of centenarians (100 subjects), their offspring and nieces/nephews (200 subjects, age-range 65-80 years, median age 70 years), and in leukocytes of 114 control subjects sex- and age-matched with the relatives of centenarians. RESULTS: The centenarians and their descendants, despite the different ages, showed similar levels of heteroplasmy which were significantly higher than levels in controls. In addition we found that heteroplasmy levels were significantly correlated in parent-offspring pairs (r = 0.263; p = 0.009), but were independent of mtDNA inherited variability (haplogroup and sequence analyses). CONCLUSION: Our findings suggest that the high degree of heteroplasmy observed in centenarians is genetically controlled, and that such genetic control is independent of mtDNA variability and likely due to the nuclear genome.

Sex and age specificity of susceptibility genes modulating survival at old age.

OBJECTIVE: We aimed to investigate the influence of the genetic variability of candidate genes on survival at old age in good health. METHODS: First, on the basis of a synthetic survival curve constructed using historic mortality data taken from the Italian population from 1890 onward, we defined three age classes ranging from 18 to 106 years. Second, we assembled a multinomial logistic regression model to evaluate the effect of dichotomous variables (genotypes) on the probability to be assigned to a specific category (age class). Third, we applied the regression model to a cross-sectional dataset (10 genes; 972 subjects selected for healthy status) categorized according to age and sex. RESULTS: We found that genetic factors influence survival at advanced age in good health in a sex- and age-specific way. Furthermore, we found that genetic variability plays a stronger role in males than in females and that, in both genders, its impact is especially important at very old ages. CONCLUSIONS: The analyses presented here underline the age-specific effect of the gene network in modulating survival at advanced age in good health.

A novel VNTR enhancer within the SIRT3 gene, a human homologue of SIR2, is associated with survival at oldest ages.

SIR2 genes control life span in model organisms, playing a central role in evolutionarily conserved pathways of aging and longevity. We wanted to verify whether similar effects may act in humans too. First, we searched for variability in the human sirtuin 3 gene (SIRT3) and discovered a VNTR polymorphism (72-bp repeat core) in intron 5. The alleles differed both for the number of repeats and for presence/absence of potential regulatory sites. Second, by transient transfection experiments, we demonstrated that the VNTR region has an allele-specific enhancer activity. Third, by analyzing allele frequencies as a function of age in a sample of 945 individuals (20-106 years), we found that the allele completely lacking enhancer activity is virtually absent in males older than 90 years. Thus the underexpression of a human sirtuin gene seems to be detrimental for longevity as it occurs in model organisms.