The Effect of a Physical Training with the Use of an Exoskeleton on Depression Levels in Institutionalized Elderly Patients: A Pilot Study.

CONTEXT: The Human Body Posturizer (HBP) is an exoskeleton used in the neurorehabilitation. The HBP may improve motor control by stimulating the pre-frontal cortex, a brain region involved also in the inhibitory modulation of the amygdala whose hyperactivity is involved in the mechanisms of depression. OBJECTIVE: The aim of the study was to investigate in institutionalized elderly patients the effects on depression of a physical training with the use of the HBP compared to a traditional training. DESIGN: Randomized controlled trial. PARTICIPANTS: 20 institutionalized patients (mean age = 88, ds = ± 5, 3 males) with moderate depression levels. INTERVENTION: The participants were randomly assigned to: a) HBP Group, which carried out physical training using the HBP; b) Excercise Group, which carried out a training without the use of the orthosis. The training was conducted for 6 months (3 sessions each week), with the same kind of exercises with or without the HBP according to the assignment group. MEASUREMENTS: Participants were evaluated at baseline using the Tinetti balance and Gait scale, the Mini Mental State Examination and the Geriatric Handicap Scale. The Geriatric Depression Scale was administered to the participants before and after the period of training. RESULTS: The two groups were homogeneous for age, baseline motor ability (risk falls), handicap score, cognitive functioning and depression levels. After 6 months of exercise training a significant reduction in depression levels was reported only in the HBP Group (p <.01). CONCLUSIONS: A positive effect of the HBP in the modulation of mood in institutionalized elderly subjects was found. It is possible to hypothesis that a traditional training without the HBP may require more time to achieve significant results. Clinical implications will be discussed.

Aging and Adherence to the Mediterranean Diet: Relationship with Cardiometabolic Disorders and Polypharmacy.

OBJECTIVES: To investigate the association between adherence to the Mediterranean Diet (Med-Diet), cardiometabolic disorders and polypharmacy. DESIGN: Cross-sectional study. SETTING: Geriatrics outpatient clinic, Policlinico Umberto I, Sapienza University of Rome. PARTICIPANTS: 508 patients (219 male, 289 female) aged 50 to 89 who were evaluated for cardiovascular and metabolic disorders. METHODS AND MEASUREMENTS: Patients underwent a comprehensive medical assessment including medical history and the use of medications. Adherence to Med-Diet was assessed using the validated Med-Diet 14-item questionnaire; for the analysis, patients were divided in high (≥8) and medium-low (<8) adherence. Polypharmacy was defined as taking ≥5 medications. RESULTS: 476 patients completed the study. Mean age was 70.4 years; 58% female. Median Med-Diet score was 8 (interquartile range, 6-9). Patients with medium-low adherence had higher body mass index (p=0.029) and higher prevalence of arterial hypertension (p<0.001), previous coronary (p=0.002) and cerebrovascular events (p=0.011), diabetes, (p<0.001) and dyslipidemia (p=0.001) compared to those at high adherence. Med-Diet score decreased with the number of cardiometabolic disorders (p<0.001). The prevalence of polypharmacy was 39%. Consumption of olive oil (p=0.005), vegetables, (p<0.001), wine (p=0.017), legumes (p=0.028), fish (p=0.046) and nuts (p=0.045) were all inversely associated with the overall number of medications. In a multivariable regression model, medium-low adherence to Med-Diet was independently associated to polypharmacy (O.R.:1.859; 95% CI 1.142 to 3.025; p=0.013), after adjusting for possible confounding factors. CONCLUSION: Med-Diet was inversely associated with cardiometabolic disorders and with polypharmacy, suggesting that improved Med-Diet adherence might potentially delay the onset of age-related health deterioration and reduce the need of multiple medications.

Fall prevention in the young old using an exoskeleton human body posturizer: a randomized controlled trial.

BACKGROUND: Fall risk in elderly has been related with physical decline, low quality of life and reduced survival. AIM: To evaluate the impact of exoskeleton human body posturizer (HBP) on the fall risk in the elderly. METHODS: 150 subjects (mean age 64.85; 79 M/71 F) with mild fall risk were randomized into two groups: 75 for group treated with human body posturizer (HBP group) and 75 for physical training without HBP group (exercise group). The effects of interventions were assessed by differences in tests related to balance and falls. Medically eligible patients were screened with Tinetti balance and Gait evaluation scale, short physical performance battery and numeric pain rating scale to determine fall risk in elderly people. RESULTS: In the HBP group there was a significant improvement in short physical performance battery, Tinetti scale and Pain Numeric rating scale with a significant reduction in fall risk (p < 0.05). In the exercise group we observed only minimal variations in the test scores. DISCUSSION: The results at the sixth and twelfth months show a twofold positive effect in the HBP group reducing fall risk and improving quality of life by reducing pain. CONCLUSION: The use of exoskeleton human body posturizer seems to be a new significant device for prevention of fall in elderly patients. Further research should be carried out to obtain more evidence on effects of robotic technology for fall prevention in the elderly.

Exercise training and music therapy in elderly with depressive syndrome: a pilot study.

OBJECTIVE: Recent studies have thrown doubt on the true effectiveness of anti-depressants in light and moderate depression. The aim of this study is to evaluate the impact of physical training and music therapy on a sample group of subjects affected by light to moderate depression versus subjects treated with pharmacological therapy only. DESIGN AND SETTING: Randomized controlled study. Patients were randomized into two groups. Subjects in the pharmacotherapy group received a therapy with antidepressant drugs; the exercise/music therapy group was assigned to receive physical exercise training combined with listening to music. The effects of interventions were assessed by differences in changes in mood state between the two groups. MAIN OUTCOME MEASURES: Medically eligible patients were screened with the Hamilton Anxiety Scale and with the Geriatric Depression Scale. We used plasmatic cytokine dosage as a stress marker. RESULTS: We recruited 24 subjects (mean age: 75.5 ± 7.4, 11 M/13 F). In the pharmacotherapy group there was a significant improvement in anxiety only (p<0.05) at 6-months. In the exercise/music therapy was a reduction in anxiety and in depression at 3-months and at 6-months (p<0.05). We noted an average reduction of the level of TNF-a from 57.67 (± 39.37) pg/ml to 35.80 (± 26.18) pg/ml. CONCLUSIONS: Our training may potentially play a role in the treatment of subjects with mild to moderate depression. Further research should be carried out to obtain more evidence on effects of physical training and music therapy in depressed subjects.

Hypovitaminosis D: which oral supplement therapy?

OBJECTIVES: the possible therapeutic role of vitamin D in different kind of diseases explains the growing interest in this vitamin due to its pleiotropic effects. This short report shows preliminary results of prevalence of hypovitaminosis D in a group of patients and proposes a oral supplement therapy effective in correcting hypovitaminosis in a short time, without side effects. METHODS: 243 patients (aged 26-93; 67 males) were enrolled at this study. We evaluated plasma levels of 25-hydroxyvitamin D [25(OH)D] with the following cut-off values: <10 ng/ml or <0-25 nmol/L (deficient), 10-30 ng/ml or 25-75 nmol/L 30-50 (insufficient) and > 30 ng/ml or > 50 nmol/L (normal). The first 73 patients with hypovitaminosis D received at baseline 25,000 IU (Cholecalciferol) per os twice a month (Tp.A). The next patients (Tp.B) at baseline received a loading dose of 50,000 IU once a week for 8 weeks, followed by a maintenance dose of 25,000 IU twice a month. RESULTS: hypovitaminosis D is a widespread condition (i.e., 82.3%) not only in elderly (75.6% of 75 patients aged <65 yrs and 86.5% of 168 subjects aged >65 yrs). Preliminary results at 6 months show that Tp.B is more effective in correcting hypovitaminosis D (baseline 14.4 ± 5.3 ng/ml; 24 wk 43.3 ± 14.7 ng/ml; p<0.0001). CONCLUSION: hypovitaminosis D is an important public health problem. We believe it is important to quickly achieve normal Vit. D plasma values in order to produce pleiotropic effects.

Screening of frailty in elderly patients with disability by the means of Marigliano-Cacciafesta polypathology scale (MCPS) and Canadian Study of Health and Aging (CSHA) scales.

Frailty is an age-related condition, characterized by a decreased homeostatic reserve and increased vulnerability to stressful events, with high risk of adverse outcomes. The aim of this study was to compare the evaluation of the frailty by the means of the MCPS and the Rockwood criteria. We enrolled 98 patients (mean age ± standard deviation, m ± SD, 80.7 ± 7.0 years) and 20 controls (82.7 ± 3.4 ys), who attended our outpatient clinic for the evaluation of disability and the renewal of driving license, respectively. The multidisciplinary geriatric assessment (MGA) was performed including the administration of the following scales for frailty: MCPS scale (range 0-245), CSHA-Rules-Based Definition of Frailty (CSHA-RBDF) (range 0-3) and CSHA-Clinical Frailty Scale (CSHA-CFS) (range 0-7). The patients and controls showed MCPS=52.39 ± 11.36 and 4.6 ± 3.28, CSHA-RBDF=2.27 ± 0.62 and 0.10 ± 0.44, CSHA-CFS=6.22 ± 0.75 and 2.95 ± 0.51, respectively (p<0.000001). Frailty scores were higher in female than in male (p=0.065 for CSHA-RDBF and p<0.05 for CSHA-CFS). The MCPS scores were significantly related to both CSHA-RDBF (r=0.753, p<0.001) and CSHA-CFS scores (r=0.793, p<0.001). The frailty scales were significantly related to disability, cognitive impairment and polypathology. In conclusion, the frail patient may be a carrier of multiple chronic pathologies and/or of physical/cognitive decline. The frail patient has to be considered the elective geriatric patient, characterized by a continuous multidimensional care requirement. MCPS is an useful tool for the frailty screening and to set up a tailored program of geriatric rehabilitation, in order to prevent or reduce the development of frailty-related complications.

Vitamin D: drug of the future. A new therapeutic approach.

Besides increasing calcium absorption in the bowel and promoting the normal formation and mineralization of bone, vitamin D exerts relevant pleiotropic effects in different tissues. Serum levels of vitamin D show correlation with the risk of infections, cardiovascular diseases, cancer and autoimmune disorders. The possible therapeutic role of vitamin D in different kind of diseases: inflammatory, immunologic, infectious and neoplastic ones, explains the growing interest in this vitamin due to its pleiotropic effects, and makes it a candidate to become a potential drug in the next future.

Self-administrated test based on the Marigliano-Cacciafesta Polypathological Scale (MCPS), as a screening tool for early identification of frailty in the elderly: a cohort study.

The aim of our study was to screen people of advanced age for "frailty", and illnesses, in order to prevent future disabilities through interventions made globally and individually to these patients. Applying the items such as those of the Marigliano-Cacciafesta Polypathological Scale (MCPS), we utilized a completely multi-dimensional evaluation. We have elaborated a series of simple and comprehensive questions enabling all participants to answer independently and easily. The results of the testing were successful. Within their limits, all the participants considered the test as a valuable instrument to assess their weaknesses. The test was especially efficient when it came to identifying problem areas in the psycho-physical state and frailty of elderly patients, as well as some loss of their own autonomy. These studies successfully tested a cohort of elderly people with similar symptoms.

New frontiers of cognitive rehabilitation in geriatric age: the Mozart Effect (ME).

The ME was described for the first time in 1993. Subsequently other studies with similar designs were performed. The present study, therefore, proposes: (i) to verify the existence of the benefits of exposure to music in elderly subjects with mild cognitive impairment (MCI), (ii) to explore whether it is possible to find any lasting improvement after training, conducted for a long period of time, with such musical pieces, in the measurable cognitive performances. The study we conducted showed that the ME is present in geriatric patients with MCI; the influence on spatial-temporal abilities remains constant in time if the stimulation is maintained. The continuation of our study will consist of increasing the number of individuals examined and in having them listen to music during the study of ECG rhythms and during the acquisition of cerebral functional magnetic resonance imaging (fMRI), and, at the same time, testing them by neuropsychometric methods.

Third degree of atrioventricular block: a rare geriatric complication that may cause sudden death. Remarks on two clinical cases.

Two clinical cases are reported that have in common the electrocardiographic detection of a third degree atrioventricular block (AVB), which occurred in the first case in a man of 78 years, hospitalized in our unit after an accidental fall with an ensuing head trauma, and in the second case, in a woman of 67 years, after cataract surgery on her left eye. The complete or third degree AVB is a bradyarrhythmia characterized by the absence of paroxystic or permanent atrioventricular conduction. Several studies conducted on subjects between the ages of 60 and 85 pointed out that the incidence of AVB-type bradyarrhythmias of a degree greater than the first is extremely rare, i.e., it is close to zero. It is, however, necessary to make an early diagnosis of the AVB, as in many cases it may complicate the patient's clinical progress and may often lead to sudden death. Clinical and experimental observations have shown that electrocardiographic alterations and arrhythmias are frequent complications of cerebral accidents such as head traumas, or of ophthalmic surgery. It is therefore necessary, especially in elderly patients in whom bradyarrhythmias are characterized by the presence of widespread histological alterations of the conduction system, to perform a 24-h monitoring of all adverse events that may lead to an AVB.

Exaggerated morning blood pressure surge and cardiovascular events. A 5-year longitudinal study in normotensive and well-controlled hypertensive elderly.

Cardiovascular events (CE) occur most frequently in the morning hours in hypertensive subjects. We studied the association between the morning blood pressure (BP) surge and CE in prognosis of 10 normotensive and 32 well-controlled hypertensive elderly, in whom ambulatory BP monitoring was performed and who were followed prospectively for 5 years. The morning surge (MS) of BP was calculated as mean systolic BP during 2h after awakening--mean systolic BP during 1h that included the lowest sleep BP. During an average of 60 months, five CE occurred. When the patients were divided into two groups according to MS, those in the top terzile (MS group; MS> or =34 mmHg, n=14) had a higher prevalence of CE (5 versus 0, p=0.001) during the follow-up period, than the others (non-MS group; MS<34 mmHg, n=28). The logistic regression analysis showed the MS sleep-trough surge as predictive variable of CE (odds ratio, OR=0.794, p=0.022). In conclusion, in older normotensives and well-controlled hypertensives, a higher BP MS is associated with vascular risk independently of clinical and ambulatory BP. Reduction of the MS could thus be a therapeutic target for preventing vascular events also in non-hypertensive patients.

The evaluation of the presence of comorbidity by the Marigliano-Cacciafesta polypathology scale (MCPS) and the cumulative illness rating scale (CIRS) in elderly subjects with disability.

Multiple factors associated with the frailty syndrome may be involved in the appearance of disability, including the presence of comorbidity. The CIRS is commonly used for the evaluation of comorbidity, consisting of two parts: the comorbidity index (CI) and the severity index (SI). A multidimensional scale, the MCPS, has been recently developed, predicting the risk to develop disability. Fifty-nine subjects were examined by a structured multidimensional geriatric assessment. The MCPS and CIRS was significantly correlated (r=0.410; p<0.01 with the CI; and r=0.443, p<0.001 with the SI). The patients were divided in two groups, according to the MCPS score. The mean activities of daily living (ADL) and instrumental activities of daily living (IADL), as well as the corrected mini-mental state examination (MMSE) score (+/-S.E.M.) were: 3.19+/-0.26; 0.28+/-0.04 and 24.00+/-1.14 in moderate-severe polypathology (n=21); 2.16+/-0.22; 0.13+/-0.02 and 21.23+/-0.72 in severe polypathology (n=38) (p<0.001, p<0.01 and p<0.05), respectively. The MCPS score was correlated with the main indices of disability. In conclusion, we found that the MCPS is a useful tool in order to quantify and classify the presence of comorbidity, with results significantly related to that obtained with the CIRS. The MCPS offers an important stratification of the patients on the base of a well-established classification, not supplied by the CIRS.

The Marigliano-Cacciafesta polypathology scale (MCPS): a tool for predicting the risk of developing disability.

The purpose of the work was to verify whether our MCPS can be a tool for predicting the risk of developing disabilities. We considered 45 elderly subjects divided into three groups of 15 subjects each. Group 1 consisted of cases with a "moderate-severe" degree of polypathology, with no associated condition of disability evaluated by means of the activities of daily living (ADL). Group 2 contained cases with a "moderate" degree of polypathology (with no associated condition of ADL disability). The Group 3 was the control group with a "mild" degree of polypathology (with no disability associated with ADL). All subjects were re-evaluated after 6 and 12 months. Both Groups 1 and 2 of cases over time developed greater disabilities, compared to the control Group 3; in particular, the subjects with "moderate-severe" polypathology were more disabled after 12 months.

The Marigliano-Cacciafesta polypathological scale: a tool for assessing fragility.

The aim of our studies was to establish a standard method of assessment that allows an early identification of frailty in the elderly, i.e., to predict who are at risk of developing disabilities, in order to be able to intervene with preventive global and individualized measures. A new multidimensional scale called Marigliano-Cacciafesta polypathological scale (MCPS) was used on 180 elderly people, together with the Barthel index (BI), the global evaluation functional index (GEFI), the geriatric depression scale (GDS), the mini mental state examination (MMSE), the mini nutritional assessment (MNA), and the Tinetti test. A strongly significant statistical correlation was found between the MCPS and the nutritional state, mood level, motor functionality, level of disability and global functionality. As the fragile patients are at a risk to develop disabilities, we think that our scale can be a significant contribution to the multidimensional geriatric assessment (MGA), aimed at identifying and quantifying the parameter of fragility of each patient, an information which should be known, if we intend to introduce preventive measures.

Cognitive function by brain event-related potentials (ERP) in elderly with borderline isolated systolic hypertension (BISH).

Several studies have shown a relationship between BISH and cerebrovascular events, but no studies have investigated a relationship with cognitive function. The aim was to assess the cognitive function in the elderly with recent BISH. According to WHO Guidelines (1999), we selected 10 elderly normotensives, 10 elderly with recently diagnosed (<2 years) BISH, and 10 elderly with recently diagnosed (<2 years) isolated systolic hypertension (ISH). They were submitted to 24-hr ambulatory blood pressure (BP) monitoring (ABPM) and to cognitive assessment by mini mental state examination (MMSE) and the recording of brain ERP, of type N2 and P300. The elderly with BISH, compared to normotensives, showed N2 wave latency values significantly higher, but similar P300 potential latency values and MMSE scores. The elderly with ISH showed N2 and P300 latency significantly higher than the normotensives. The gradual increase of the ERP latency values of the BISH and ISH elderly, in comparison to the normotensives, seems to indicate a gradual alteration of the cognitive processes related to the increase of BP.

Sleep quality of centenarians: cognitive and survival implications.

Sleep is an active nervous process, which is structured in phases characterized by subsequent cycles of various psycho-physiological phenomena. It performs vital, yet mysterious functions and is in all likelihood involved in many processes, including cognitive processes. In old age the internal structure of sleep changes, but these physiological variations allow, in healthy subjects, a satisfactory quantity and quality of sleep. Until now there have been no literature reports of studies regarding sleep quality in extreme old age. Our work describes the investigation of the quality of sleep in a sample of 180 centenarians selected from the registered residents of Rome. We have studied sleep disorders, related pathologies and pharmacological treatments. The results of the study show good sleep quality for 57.4% of the sample group; 35.2% complain of medium intensity problems, significantly related to angina pectoris and to chronic obstructive bronchopneumopathy. Only 7.4% of the subjects showed severe problems, significantly related with cognitive deficiency and lower survival rate. The results of our study confirm, in centenarians as in the elderly, the existence of a positive correlation between sleep quality, survival and successful aging.

Blood pressure variability and cognitive function in older hypertensives.

Several studies have shown that cerebrovascular organ damage can related not only to average blood pressure (BP) levels, but also to BP variability. The aim of this study was to investigate the relationship between 24 hr BP variability and cognitive function in older hypertensives. Forty older, never treated hypertensives were submitted to 24 hr ambulatory BP monitoring (ABPM) and subdivided, according to the variability of the systolic BP (SBP), in two groups: 23 with higher (> PV) and 17 with lower (< PV) SBP variability, defined as the standard deviation (SD) of the mean 24 hr SBP values and as coefficient of variation (CV). They underwent a cognitive assessment by mini mental state examination (MMSE) and a recording of the brain event-related potentials (ERPs). ERPs record neuronal electric activity when the patients are submitted to frequent and rare acoustic stimuli and must recognize and count rare (target) stimuli. The two groups with statistically different 24 hr SBP variability, did not show significant differences in MMSE scores or in N2 and P300 ERP latencies, thus indicating a lack of difference in the cognitive ability between the two groups. Our results show that cognitive function is not related to 24 hr SBP variability in older hypertensives.