Health care for older people in Italy: The U.L.I.S.S.E. Project (Un link informatico sui servizi sanitari esistenti per l'anziano - a computerized network on health care services for older people).

OBJECTIVES: The U.L.I.S.S.E. study is aimed at describing older patients who are cared for in hospitals, home care or nursing homes in Italy. DESIGN: The U.L.I.S.S.E. study is an observational multicenter prospective 1-year study. SETTING: Overall, 23 acute geriatric or internal medicine hospital units, 11 home care services and 31 nursing homes participated in the study. MEASUREMENTS: The patient's evaluation was performed using comprehensive geriatric assessment instruments, i.e. the interRAI Minimum Data Set, while data on service characteristics were recorded using ad-hoc designed questionnaires. RESULTS: The older subjects who are in need of acute and long term care in Italy have similar characteristics: their mean age is higher than 80 years, they have a high level of disability in ADL, an important multimorbidity, and are treated with several drugs. The prevalence of cognitive impairment is particularly high in nursing homes, where almost 70% of residents suffer from it and 40% have severe cognitive impairment. On the other hand, there is a shortage of health care services, which are heterogeneous and fragmented. CONCLUSIONS: Health care services for older people in Italy are currently inadequate to manage the complexity of the older patients. An important effort should be undertaken to create a more integrated health care system.

Construct validity of the 15-item geriatric depression scale in older medical inpatients.

The construct validity of the 15-item Geriatric Depression Scale (sfGDS) has been assessed in selected populations. The aim of this study was to assess the appropriateness of applying the sfGDS to unselected older inpatients. The main component analysis of sfGDS was performed in 2032 medical inpatients (mean age = 76.3 +/- 8.4). sfGDS did not qualify as a unidimensional test. Three factors explained 47.7% of variance and explored the following dimensions: positive attitude toward life, distressing thoughts/negative judgment about the own condition, and inactivity/reduced self-esteem. The internal homogeneity was poor (Cronbach's alpha = .46). A higher fraction of variance was explained in patients independent in all or dependent in > or = 1 activity of daily living (ADL). In older medical inpatients, sfGDS is not a single construct, which prevents the univocal interpretation of the final score. The higher fraction of explained variance in patients with comparable ADL performance probably reflects the dependency of affective from physical status.

Construct validity of the abbreviated mental test in older medical inpatients.

OBJECTIVES: To evaluate validity and internal structure of the Abbreviated Mental Test (AMT), and to assess the dependence of the internal structure upon the characteristics of the patients examined. DESIGN: Cross-sectional examination using data from the Italian Group of Pharmacoepidemiology in the Elderly (GIFA) database. SETTING: Twenty-four acute care wards of Geriatrics or General Medicine. PARTICIPANTS: Two thousand eight hundred and eight patients consecutively admitted over a 4-month period. MEASUREMENTS: Demographic characteristics, functional status, medical conditions and performance on AMT were collected at discharge. Sensitivity, specificity and predictive values of the AMT <7 versus a diagnosis of dementia made according to DSM-III-R criteria were computed. The internal structure of AMT was assessed by principal component analysis. The analysis was performed on the whole population and stratified for age (<65, 65-80 and >80 years), gender, education (<6 or >5 years) and presence of congestive heart failure (CHF). RESULTS: AMT achieved high sensitivity (81%), specificity (84%) and negative predictive value (99%), but a low positive predictive value of 25%. The principal component analysis isolated two components: the former component represents the orientation to time and space and explains 45% of AMT variance; the latter is linked to memory and attention and explains 13% of variance. Comparable results were obtained after stratification by age, gender or education. In patients with CHF, only 48.3% of the cumulative variance was explained; the factor accounting for most (34.6%) of the variance explained was mainly related to the three items assessing memory. CONCLUSION: AMT >6 rules out dementia very reliably, whereas AMT <7 requires a second level cognitive assessment to confirm dementia. AMT is bidimensional and maintains the same internal structure across classes defined by selected social and demographic characteristics, but not in CHF patients. It is likely that its internal structure depends on the type of patients. The use of a sum-score could conceal some part of the information provided by the AMT.

Trends in prescribing ACE-inhibitors for congestive heart failure in elderly people.

BACKGROUND AND AIMS: The aim of this study was to analyze trends in the use of ACE-inhibitors in patients aged 65 and older with congestive heart failure (CHF) in the period from 1988 to 1998. METHODS: We studied 2985 patients (mean age 79.7 +/- 7 years), hospitalized for CHF in 12 different bimonthly periods. Home therapy prior to hospitalization was assessed retrospectively, and data on in-hospital therapy and discharge prescriptions were collected prospectively. RESULTS: Diuretics and digitalis were the most commonly used and prescribed drugs. The use of ACE-inhibitors between 1988 and 1998 increased from 13.4 to 46.7% prior to hospitalization, and from 25.8 to 59.2% as a discharge prescription. The most important factors associated with a prescription of ACE-inhibitors at discharge were previous use (OR 4.35, 95% CI=3.65-5.19), hypertension (OR 1.76, 95% CI=1.47-2.11), valvular heart diseases (OR 2.06, 95% CI=1.51-2.81) and diabetes (OR 1.58, 95% CI=1.29-1.93). Physical impairment was associated with a decreased use of ACE-inhibitors at discharge (OR 0.55, 95% CI=0.45-0.67). CONCLUSIONS: The use of ACE-inhibitors for the treatment of CHF progressively increased both at home and in hospital wards of general medicine and geriatrics in the 10-year period studied. Nevertheless, digitalis and diuretics continue to be the most commonly prescribed drugs. A widespread educational effort is needed to increase physicians' awareness of the rationale for prescribing ACE-inhibitors for CHF patients.

Trends in antihypertensive drugs in the elderly: the decline of thiazides.

The last decade has seen the publication of different editions of guidelines for the pharmacological treatment of hypertension that were based on the results of large, randomised trials. Since these guidelines were meant to inform practitioners, we analysed the pattern of prescription of antihypertensive agents between 1988 and 1997 among older hospitalised adults. Because of the wealth of data supporting the use of thiazides diuretics, we focused on diuretic prescription, to identify independent predictors of their utilisation. To this end, we used the GIFA database that includes patients admitted to academic medical centres throughout Italy between 1988 and 1997. We studied 5061 patients over 65 years of age selected among a population of 28 411, based on the diagnosis of arterial hypertension at discharge. The use of ACE-inhibitors has been raising steadily through the years, and they are the agents most commonly used since 1996. Calcium channel blockers showed a similar trend and were the top prescribing drug until 1995; afterwards, the documentation of potentially severe side effects has resulted in a nearly 20% reduction of their use. Beta-blockers have remained unpopular throughout the decade. Instead, the prescription of diuretics as a class showed a biphasic trend; an initial decrease with a prolonged steady state and a more recent raise. However, at a separate analysis, it was a evident that a progressive increase of the use of loop diuretics since 1988 has been paralleled by a nearly 50% reduction of thiazides prescriptions. Loop diuretics were more likely to be prescribed to older individuals, those with cardiac heart failure, coronary heart disease and high creatinine level. In contrast, independent predictors of thiazides use were female gender, good functional status, preserved renal function, and absence of cardiovascular comorbidity. In conclusion, despite continued recommendations to use thiazides diuretics for the treatment of hypertension among older individuals, their use has been declining steadily between 1988 and 1997. A possible explanation is that the choice to prescribe a thiazides diuretic is influenced by age, functional status and comorbidity.

Predicting length of stay of older patients with exacerbated chronic obstructive pulmonary disease.

Our study objective was to identify factors predicting length of hospital stay of older patients with exacerbated chronic obstructive pulmonary disease (COPD) through a multicenter, cross-sectional, retrospective study. We examined 3789 patients aged 74.3+/-11.1 years (mean+/-SD), 66.1% males, consecutively hospitalized in 32 wards of General Medicine and 31 of Geriatrics in acute care hospitals for exacerbated COPD in 10 bimonthly periods between 1988 and 1997. On admission, patients underwent a structured assessment of demographic data, nutritional status, cognitive and physical functions, comorbidity, and pharmacological therapy in the two weeks prior to admission. Patients were grouped according to whether their length of stay exceeded or not the 75th percentile of stay distribution in each bimonthly period. Variables univariately distinguishing groups were entered into a logistic regression analysis having long-stay as the dependent variable. Living alone (Odds Ratio 1.33, 95% Confidence Limits 1.03-1.70), use of more than 3 drugs prior to admission (OR 1.29, CL 1.09-1.51), use of drugs with respiratory depressant properties prior to admission (OR 1.24, CL 1.05-1.46), and the presence of more than 3 comorbid diseases (OR 1.88, CL 1.61-2.19) were independent correlates of long-stay. Age did not predict length of stay. In conclusion, selected health outcomes and indicators of disease severity, but not age, target COPD patients at risk of long-stay. Research is needed to verify whether these data can help program interventions aimed at shortening length of stay and, thus, at reducing annual hospitalization costs of the elderly.

Cognitive dysfunction as a major determinant of disability in patients with heart failure: results from a multicentre survey. On behalf of the GIFA (SIGG-ONLUS) Investigators.

Cognitive dysfunction is a frequent finding among older patients with left ventricular systolic dysfunction; however, the clinical outcomes of such a finding are unknown. Also, disability is a common condition in heart failure, poorly responding to commonly used cardiovascular medications. The association between cognitive dysfunction and disability was assessed in 1583 patients with heart failure, but without cerebrovascular disease, previous stroke, or Alzheimer's disease, who were enrolled during 2 years of a multicentre pharmacoepidemiology survey. The association between groups of variables (demographics, comorbid conditions, medications, and objective tests, including the Hodkinson abbreviated mental test) and functional disability (as indicated by need for intensive assistance in at least one of Katz' activities of daily living) was first analysed using separate age and sex adjusted logistic regression models. Those variables, significant at a p<0.1 level in these models, were simultaneously entered into an age and sex adjusted summary regression model. Among 1583 patients suitable for analysis, cognitive dysfunction (as detected by abbreviated mental test score <7) was detected in 265/461 disabled patients, and in 150/1122 independent subjects (p<0.0001). According to logistic regression analysis, cognitive dysfunction was associated with disability (OR=6.49; 95% CI=4.39-9.59) after adjusting for potential confounders.Thus, cognitive dysfunction in patients with heart failure is independently associated with disability, which currently represents an overwhelming medical and financial problem to patients, caregivers, and public health services. As early recognition and treatment of low cardiac output states might reverse cognitive dysfunction, cost effective treatment for heart failure should include systematic diagnostic and therapeutic approaches to cognitive dysfunction.

Study on COgnition and Prognosis in the Elderly (SCOPE).

The Study on COgnition and Prognosis in the Elderly (SCOPE) is a multicentre, prospective, randomized, double-blind, parallel-group study designed to compare the effects of candesartan cilexetil and placebo in elderly patients with mild hypertension. The primary objective of the study is to assess the effect of candesartan cilexetil on major cardiovascular events. The secondary objectives of the study are to assess the effect of candesartan cilexetil on cognitive function and on total mortality, cardiovascular mortality, myocardial infarction, stroke, renal function, hospitalization, quality of life and health economics. Male and female patients aged between 70 and 89 years, with a sitting systolic blood pressure (SBP) of 160-179 mmHg and/or diastolic blood pressure (DBP) of 90-99 mmHg, and a Mini-Mental State Examination (MMSE) score of 24 or above, are eligible for the study. The overall target study population is 4000 patients, at least 1000 of whom are also to be assessed for quality of life and health economics data. After an open run-in period lasting 1-3 months, during which patients are assessed for eligibility and those who are already on antihypertensive therapy at enrolment are switched to hydrochlorothiazide 12.5 mg o.d., patients are randomized to receive either candesartan cilexetil 8 mg once daily (o.d.) or matching placebo o.d. At subsequent study visits, if SBP remains >160 mmHg, or has decreased by <10 mmHg since the randomization visit, or DBP is >85 mmHg, study treatment is doubled to candesartan cilexetil 16 mg o.d. or two placebo tablets o.d. Recruitment was completed in January 1999. At that time 4964 patients had been randomized. All randomized patients will be followed for an additional 2 years. If the event rate is lower than anticipated, the follow-up will be prolonged.

Impact of integrated home care services on hospital use.

OBJECTIVE: To examine the effect of a home care program based on comprehensive geriatric assessment and case management on hospital use and costs among frail older individuals. DESIGN: Quasi-experimental study with a 6-month follow-up. SETTING: Vittorio Veneto, a town in northern Italy. PARTICIPANTS: One hundred fifteen frail older people who applied for integrated home care services. INTERVENTION: Each patient was assessed with the Minimum Data Set for Home Care, and, subsequently, a case manager and a multidisciplinary team delivered social and health care services as indicated. MAIN OUTCOME MEASURES: We determined the hospital admissions and days spent in the hospital for all subjects during the first 6 months after the implementation of the home care program and compared them with the rate of hospitalization that the same patients had experienced in the 6 months preceding the implementation of the program. RESULTS: After the implementation of the integrated home care program, there was a significant reduction in the number of hospitalizations compared with pre-implementation (56% vs 46%, respectively; P < .001), associated with a reduction in the number of hospital days, both at the individual patient level (28+/-23 days vs 18+/-15 days, respectively; P < .01) and for each admission (16+/-12 days vs 12+/-8 days, respectively; P < .01). This resulted in a 29% cost reduction with an estimated savings of $1260 per patient. CONCLUSIONS: The implementation of an integrated home care program based on the use of a comprehensive geriatric assessment instrument guided by a case manager has a significant impact on hospitalization and is cost-effective.

Changes in nutritional status during the hospital stay: a predictor of long-term survival.

The objectives of this prospective observational study were to assess whether: 1) midarm circumference (MAC), previously shown to predict in-hospital mortality, maintains its prognostic implication after discharge; 2) in-hospital changes in aspecific indicators of the health status are predictors of long-term survival. The study population consisted of 249 patients from the general community [mean age 80 +/- 7 (70-99) years], consecutively discharged from geriatric and medical wards of an acute care hospital. Changes in health status during hospitalization were recorded (dynamic or delta variables) and health-related variables were collected at discharge (discharge variables). The relationship of both sets of variables to survival over a 3-year period was assessed by Cox's proportional hazards regression analysis. The discriminatory efficacy of predictive models was estimated by the Hanley and McNeil method. Survival curves were drawn with the patients alternatively grouped according to the presence or absence of each of the predictive variables. Serum albumin < 3.5 g/dL (hazard rate = 0.57, 95% confidence limits = 0.33-0.96) and dependency in at least one ADL (h.r. = 0.87, c.l. = 0.79-0.98) were found to be associated with increased mortality, and delta MAC (h.r. = 1.03, c.l. = 1.01-1.05), i.e., there was a positive change or no change in MAC from admission to discharge, with increased survival. A slightly weaker predictive model was obtained using only discharge variables. However, Hanley and McNeil's analysis showed that both models were far from achieving the optimal discrimination of high from low risk subjects. Effects on survival of individual variables varied in magnitude and dependency on time. We concluded that measuring in-hospital changes in nutritional status might improve prediction of long-term survival. Attempts should be made to identify variables having the strongest prognostic implications, and to tailor dynamic assessment to the needs of selected categories of patients.

Physiotherapy and occupational therapy: a geriatric experience in the acute care hospital.

The continuously growing segment of the geriatric population with the high incidence and prevalence of comorbidity and disability suggests that enhanced preventive and rehabilitative programs will be mandatory. The early arrangement of comprehensive assessment and rehabilitation services is extremely important not only in preventing the decline of patients in the acute care settings and successive prolonged care before discharge, but also in improving functional status at discharge. We have considered the effectiveness of a rehabilitation program in acute medical care of the elderly. This article discusses a pilot project being carried out at Catholic University Hospital "A. Gemelli" of Rome.

Digitalis in the treatment of heart failure in the elderly. The GIFA study results.

Digitalis glycosides have played an important role in the treatment of patients with heart failure (HF) for more than two centuries. Despite the introduction of new therapeutic strategies in the treatment of HF, and controversies regarding the role of digitalis in HF in sinus rhythm and its effect on mortality, digoxin is one of the most commonly prescribed drugs in the community and in hospital settings, particularly in the elderly. The Italian Group of Pharmacosurveillance in the Elderly (GIFA) monitored 20,047 hospitalized patients in 1988, 1991 and 1993, and found that digoxin was the most frequently prescribed drug in the management of HF. Inappropriate prescriptions of digitalis, defined with standardized criteria, were uncommon, and the mean daily dosage was low. Compared to earlier studies the incidence rate of adverse drug reactions (ADRs) to digoxin, was also low. The reduction in ADRs incidence was probably due to a better understanding of digoxin pharmacokinetics and to a lower daily dosage in the elderly. Nevertheless, digoxin toxicity was significantly more frequent in patients aged >or= 80 years than in those aged < 65 and and 65-79 years. In a multidrug approach to the treatment of chronic HF, digoxin exerts clinical benefits also in patients with sinus rhythm, it is not costly, it is easy to administer, and toxic effects are not common.

A simple program to train case managers in community elderly care.

The case manager, like many "new professions" does not yet have a defined curriculum. We consider that the principal requisite for case managers is a proficient knowledge of assessment for the care of elderly. Therefore, we focused a four-week teaching course for future case managers on the National Resident Assessment Instrument (RAI) of the United States and the Long-Term Care Program Application and Admission Form of British Columbia, Canada. We verified that this simple program provides students with adequate skills to become case managers.

Inotropic agents in older patients with chronic heart failure--current perspectives.

Until recently, inotropic therapy has been regarded as the most direct remedy for the left ventricular systolic dysfunction that often underlies the development of heart failure. Nevertheless, all the agents with significant inotropic properties that have been evaluated to date (such as beta adrenergic stimulants, phosphodiesterase inhibitors, and high-dose vesnarinone) showed significant increases in mortality with long-term administration. However, it is noteworthy that the participants in trials to evaluate inotropic therapy were not representative of geriatric heart failure patients for age, gender, and comorbidity. Thus, results from these studies must be interpreted cautiously when treatment for chronic heart failure must be applied to elderly subjects. At present, digitalis is the only inotropic agent recommended for long-term treatment, because it improves symptoms and prevents disease progression through neurohormonal and baroreceptor mechanisms; nevertheless, its long-term safety is still undetermined. The role of low-dose vesnarinone, pimobendan and ibopamine, which share neurohormonal, rather than inotropic, mechanisms of action, is still under investigation. Pending the definition of these issues, ACE-inhibitors and diuretics remain the mainstay of therapy for chromic heart failure.

Nutritional assessment: a primary component of multidimensional geriatric assessment in the acute care setting.

OBJECTIVE: To test the prognostic role of nutritional variables as a component of geriatric multidimensional assessment and to study the effect of hospitalization on nutritional status. DESIGN: Validation cohort study: multidimensional assessment on admission and at discharge and a weekly nutritional assessment. SETTING: General Medicine and Geriatrics wards in an acute-care university hospital. PATIENTS: A consecutive sample of 302 patients aged 79 +/- 6 years, range 70-96 years. MAIN OUTCOME MEASURES: Mortality, longstay (> 29 days), loss of lean body mass as expressed by a negative change in mid-arm muscle circumference (MAMC). RESULTS: Incidence of mortality, longstay, and decreased MAMC was 6.9%, 24.8%, and 64.2%, respectively. According to logistic regression analysis, mortality was independently predicted by preadmission dependency in at least one Activity of Daily Living (odds ratio = 2.08, confidence limits = 1.19-3.65), clinical diagnosis of malnutrition (OR = 1.89, CL = 1.11-3.21), serum albumin < 3.5 g/dL (OR = 1.82, CL = 1.06-3.14). This predictive model allowed us to recognize 75% of the patients at risk of death by targeting 23% of the population. Longstay was independently predicted by stroke (OR = 1.54, CL = 1.01-2.35), clinical diagnosis of malnutrition (OR = 1.41, CL = 1.04-1.93), and more than five comorbid diseases (OR = 1.39, CL = 1.01-1.94). Dependency in at least one ADL was the only independent predictor of decreased MAMC (OR = 1.71, CL = 1.27-2.30). CONCLUSIONS: Nutrition variables are a cardinal component of multidimensional assessment in the acute-care setting. Nutritional status deteriorates during the hospital stay, mostly in physically dependent patients.