Incidence of young-onset dementia in Italy: The Brescia register study.

INTRODUCTION: The goal of the present work was to assess the incidence of dementia with onset before the age of 65 years (i.e., young-onset dementia [YOD]) and define the frequencies of young-onset Alzheimer's disease (AD), frontotemporal lobar degeneration (FTLD), and dementia with Lewy bodies (DLB) in the general population. METHODS: The study was conducted from January 1, 2019 to December 31, 2019 in Brescia province (population: 1,268,455). During the study period, all new YOD cases (incident YOD) were counted, and all patients' records reviewed. The incidence was standardized to the Italian general population in 2019. RESULTS: A total of 29 YOD patients were diagnosed. The age-sex standardized incidence rate was 4.58 (95% confidence interval, 3.07-6.58) per 100,000 person-years. No difference in incidence rate between YOD due to AD or FTLD (P = 0.83) and between sexes (P = 0.81) was observed. YOD incidence increased with age, reaching its peak after 60 years. DISCUSSION: Presenting neurodegenerative YOD phenotypes encompasses both AD and FTLD. Improved knowledge on YOD epidemiology is essential to adequately plan and organize health services.

The impact of COVID-19 on health status of home-dwelling elderly patients with dementia in East Lombardy, Italy: results from COVIDEM network.

BACKGROUND: COVID-19 outbreak has led to severe health burden in the elderly. Age, morbidity and dementia have been associated with adverse outcome. AIMS: To evaluate the impact of COVID-19 on health status in home-dwelling patients. METHODS: 848 home-dwelling outpatients with dementia contacted from April 27 to 30 and evaluated by a semi-structured interview to evaluate possible health complication due to COVID-19 from February 21 to April 30. Age, sex, education, clinical characteristics (including diagnosis of dementia) and flu vaccination history were obtained from previous medical records. Items regarding change in health status and outcome since the onset of the outbreak were collected. COVID-19 was diagnosed in patients who developed symptoms according to WHO criteria or tested positive at nasal/throat swab if hospitalized. Unplanned hospitalization, institutionalization and mortality were recorded. RESULTS: Patients were 79.7 years old (SD 7.1) and 63.1% were females. Ninety-five (11.2%) patients developed COVID-19-like symptoms. Non COVID-19 and COVID-19 patients differed for frequency of diabetes (18.5% vs. 37.9%, p < 0.001), COPD (7.3% vs. 18.9%, p < 0.001), and previous flu vaccination (56.7% vs. 37.9%, p < 0.001). Diabetes and COPD were positively associated with COVID-19, whereas higher dementia severity and flu vaccination showed an inverse association. Among COVID-19 patients, 42 (44.2%) were hospitalized while 32 (33.7%) died. Non COVID-19 patients' hospitalization and mortality rate were 1.9% and 1.2%, respectively. COVID-19 and COPD were significantly associated with the rate of mortality. DISCUSSION/CONCLUSIONS: A high proportion of adverse outcome related to COVID-19 was observed in home-dwelling elderly patients with dementia. Active monitoring though telehealth programs would be useful particularly for those at highest risk of developing COVID-19 and its adverse outcomes.

Assessment of the Incremental Diagnostic Value of Florbetapir F 18 Imaging in Patients With Cognitive Impairment: The Incremental Diagnostic Value of Amyloid PET With [18F]-Florbetapir (INDIA-FBP) Study.

IMPORTANCE: Cerebral amyloidosis is a key abnormality in Alzheimer disease (AD) and can be detected in vivo with positron emission tomography (PET) ligands. Although amyloid PET has clearly demonstrated analytical validity, its clinical utility is debated. OBJECTIVE: To evaluate the incremental diagnostic value of amyloid PET with florbetapir F 18 in addition to the routine clinical diagnostic assessment of patients evaluated for cognitive impairment. DESIGN, SETTING, AND PARTICIPANTS: The Incremental Diagnostic Value of Amyloid PET With [18F]-Florbetapir (INDIA-FBP) Study is a multicenter study involving 18 AD evaluation units from eastern Lombardy, Northern Italy, 228 consecutive adults with cognitive impairment were evaluated for AD and other causes of cognitive decline, with a prescan diagnostic confidence of AD between 15% and 85%. Participants underwent routine clinical and instrumental diagnostic assessment. A prescan diagnosis was made, diagnostic confidence was estimated, and drug treatment was provided. At the time of this workup, an amyloid PET/computed tomographic scan was performed, and the result was communicated to physicians after workup completion. Physicians were asked to review the diagnosis, diagnostic confidence, and treatment after the scan. The study was conducted from August 5, 2013, to December 31, 2014. MAIN OUTCOMES AND MEASURES: Primary outcomes were prescan to postscan changes of diagnosis, diagnostic confidence, and treatment. RESULTS: Of the 228 participants, 107 (46%) were male; mean (SD) age was 70.5 (7) years. Diagnostic change occurred in 46 patients (79%) having both a previous diagnosis of AD and an amyloid-negative scan (P < .001) and in 16 (53%) of those with non-AD diagnoses and an amyloid-positive scan (P < .001). Diagnostic confidence in AD diagnosis increased by 15.2% in amyloid-positive (P < .001; effect size Cohen d = 1.04) and decreased by 29.9% in amyloid-negative (P < .001; d = -1.19) scans. Acetylcholinesterase inhibitors and memantine hydrochloride were introduced in 61 (65.6%) patients with positive scan results who had not previously received those drugs, and the use of the drugs was discontinued in 6 (33.3%) patients with negative scan results who were receiving those drugs (P < .001). CONCLUSIONS AND RELEVANCE: Amyloid PET in addition to routine assessment in patients with cognitive impairment has a significant effect on diagnosis, diagnostic confidence, and drug treatment. The effect on health outcomes, such as morbidity and mortality, remains to be assessed.

Changes in characteristics of Alzheimer patients at first visit to centers for dementia: a 10-year follow-up study.

BACKGROUND AND AIMS: The Cronos Project is an observational study on Alzheimer's disease (AD), created by Italy's Ministry of Public Health in 2000. The aim of our study was to evaluate whether the clinical characteristics of patients at their first visit to the Alzheimer Evaluation Unit (UVA) changed from September 2000 to December 2009, and to examine possible reasons for changes noted. METHODS: 1532 consecutive patients were enrolled in two UVAs (September 2000 to December 2009) in a retrospective, descriptive study, with medical records as the primary source of data. RESULTS: Patients' age at the first visit was not different throughout the period of observation. No differences were observed with regard to education or functional characteristics. However, a reduction in the severity of cognitive impairment was found during the period of evaluation: patients consecutively recruited in the first years were more cognitively, functionally, and psycho- behaviorally compromised than patients recruited in the following years. CONCLUSIONS: Data show changes in characteristics at the first visit in patients affected by cognitive deterioration during the years of observation. This finding indicates new clinical needs of patients, requiring changes in pharmacological treatment and in general of the clinical approach.

Delirium in a sub-intensive care unit for the elderly: occurrence and risk factors.

BACKGROUND AND AIMS: The objective was to study occurrence and risk factors of delirium in a new model of care, the Sub-Intensive Care Unit for the elderly (SICU), which is a level of care between that offered by ordinary wards and intensive care. METHODS: A prospective observational study of 401 consecutively admitted patients, 60+ years, in a four-bed SICU in the geriatric ward of a general hospital. Delirium was detected by the Confusion Assessment Method (CAM) at admission (prevalent) and during SICU stay (incident). Impaired function (Barthel Index) and/or IADL two weeks prior to admission identified disability, and additional Mini-Mental State Examination (MMSE) <18 at discharge identified probable dementia. RESULTS: Delirium was detected in 117 patients (29.2%). Of these 62 (15.5%) had delirium at admission and a further 55 developed delirium during their time in the SICU. Delirium occurred in 19 (11.4%) of the "robust" (no dementia or disability), 28 (24.1%) of the disabled and 70 (58.4%) of the demented patients (p<0.001). Prevalent delirium was found in 8 (4.8%), 11 (9.5%) and 43 (36.1%) (p<0.001) and incident in 11 (6.6%), 17 (14.7%) and 27 (22.7%) (p<0.001) of the robust, disabled, and demented patients respectively. Heavy alcohol use, maximum intake of 7 or more drugs, and the use of a bladder catheter were independently associated with delirium. CONCLUSIONS: Delirium was common in the SICU, and patients with probable dementia had the highest risk. They tended to have delirium at admission, whereas patients without dementia, although less at risk, were more prone to developing delirium during their stay in the SICU.

Subintensive care unit for the elderly: a new model of care for critically ill frail elderly medical patients.

OBJECTIVE: An increasing number of elderly patients are admitted to the hospital for critical diseases and the gap between supply and demand of intensive care resources is a growing problem. To meet this challenge, 4 beds in a 24-bed acute care for the elderly (ACE) medical unit were dedicated to a subintensive care unit (SICU). Severely ill elderly medical patients, requiring a higher level of care than provided in ordinary wards, are admitted. The aim of the study was to describe the characteristics of the setting and to discuss its usefulness based on data obtained after the first period of implementation. METHODS: This article describes the development, management, economics and patient characteristics of the SICU. Patient care combines the ACE model with a highly specialised medical care. Patients admitted to the SICU are compared with patients treated in the ordinary ACE unit before the SICU opened. All patients received a multidimensional evaluation, including demographics, main diagnosis, number of chronic somatic diseases, Charlson index, APACHE II score, APACHE-APS subscore, number of currently administered drugs, serum albumin, cognitive status (Mini-Mental State Examination), depression (Geriatric Depression Scale) and functional status (basic and instrumental activities of daily living). Ward physicians performed assessment and collection of data. RESULTS: During the first 16 months, 489 patients were admitted, 401 according to the selection criteria (60 +/- years and APACHE II score > or =5 and/or APACHE-APS score > or =3). Mean age was 78.1 years, mean APACHE II score 14.5 (moderate severity) and non-invasive mechanical ventilation was received by 87 (21.7%). The most common diagnoses were respiratory failure, cardiac disease and stroke. Mean length of stay in the SICU was 61.8 h, and 6.0 days in the hospital. Compared with ACE-unit patients admitted during 2002 (n=1380), SICU patients were obviously more seriously ill (APACHE II score 14.5 vs 6.7). When comparing patients of same illness severity (APACHE-APS score > or =3) (n=125), patients treated in the SICU had lower in-hospital mortality than those treated in the ordinary ACE ward (12.5 vs 19.2%). Only a few patients (3.5%) were transferred to the intensive care unit as a consequence of increased severity of illness. CONCLUSIONS: The SICU is an innovative method to treat frail elderly patients with more severe conditions. Low hospital mortality compared with that of severe patients in the ACE unit supports the usefulness of this model. It could be implemented in medical units of large hospitals in order to give optimal care and advanced interventions to the frail elderly and to avoid intensive care unit overcrowding.

Relationship between functional loss before hospital admission and mortality in elderly persons with medical illness.

OBJECTIVE: This hospital-based prospective study tests the hypothesis that, in a large group of hospitalized elderly patients, those who report functional decline between pre-illness baseline and hospital admission have a higher risk of death. METHODS: Nine hundred fifty elderly ambulant patients (F = 69.3%; mean age 78.3 +/- 8.5 years) were consecutively admitted to a geriatric ward (Poliambulanza Hospital, Brescia, Italy) during a 15-month period. Number and severity of somatic diseases, Charlson Index score, APACHE II score, level of serum albumin, cognitive status (by Mini-Mental State Examination), and depression score (by Geriatric Depression Scale), were assessed on admission and evaluated as potential prognostic factors. Functional status (by Barthel Index) was assessed by self-report on admission. Preadmission function was also assessed by self-report at the time of admission. Impairment of function due to an acute event is measured as the difference between performances on admission and 2 weeks before the acute event. Six-month survival was the main outcome variable. RESULTS: Factors related to mortality in bivariate analysis were: male sex, age over 80, cancer, congestive heart failure, pulmonary diseases, elevated Charlson Index score, and (independently) dementia (Mini-Mental State Examination < 18), APACHE-Acute Physiology Score , albumin level <3.5 g/dL, and anemia. After controlling for these variables and for Barthel Index score 2 weeks before the acute event, change in function due to the acute disease is independently related to 6-month mortality (minor functional change [<30 Barthel Index Point] relative risk: 1.3, 95% confidence interval, 0.6-3.0 and major functional change [major functional decrement] relative risk: 2.8, 95% confidence interval, 1.3-5.7). CONCLUSIONS: Disease-induced disability may reflect a condition of biological inability to react to acute diseases (i.e., frailty), and should be assessed as a relevant prognostic indicator.