The management of syncope in older adults.

Syncope is a frequent symptom in older patients. The diagnostic and therapeutic management may be complex, particularly in older adults with syncope and comorbidities or cognitive impairment. Morbidity related to syncope is more common in older persons and ranges from loss of confidence, depressive illness and fear of falling, to fractures and consequent institutionalization. Moreover, advan-ced age is associated with short and long-term morbidity and mortality after syncope. A standardized approach may obtain a definite diagnosis in more than 90% of the older patients with syncope and may reduce diagnostic tools and hospitalizations. The initial evaluation, including anamnesis, medical examination, orthostatic hypotension test and electrocardiogram (ECG), may be more difficult in the elderly, specially for the limited value of medical history, particularly for the certain diagnosis of neuro-mediated syncope. For this reason neuroautonomic assessment is an essential step to confirm a suspect of neuromediated syncope. Orthostatic blood pressure measurement, head up tilt test, carotid sinus massage and insertable cardiac monitor are safe and useful investigations, particularly in older patients. The most common causes of syncope in the older adults are orthostatic hypotension, carotid sinus hypersensitivity, neuromediated syncope and cardiac arrhythmias. The diagnostic evaluation and the treatment of cardiac syncope are similar in older and young patients and for this reason will not be discussed. In older patients unexplained falls could be related to syncope, particularly in patients with retrograde amnesia. There are no consistent differences in the treatment of syncope between older and younger population, but a specific approach is necessary for orthostatic hypotension, drug therapy and pacemaker implantation.

Physical performance and creative activities of centenarians.

The human functional autonomy is reduced progressively with advancing age, although a considerable proportion of the centenarians maintain a good level of autosufficiency for the basic performance of the everyday life. Even if males have a lower probability to reach the centenarian age than females do, the male centenarians display generally better functional conditions than the females. Actually, there are no systemic studies on centenarian works or activities; nevertheless, the examples of several representative persons (artists, scientists, explorers, etc.) who remained active even after this age indicate that such a possibility is realistic, and that the maintenance of vital interest and passions, thus preserving competence and professional attitudes, is not in conflict with the reaching of extreme longevity.

Prognostic value of International Diabetes Federation and Adult Treatment Panel III definitions of metabolic syndrome in Type 2 diabetic patients: what makes the difference?

AIM: The International Diabetes Federation (IDF) proposed new diagnostic criteria for metabolic syndrome (MS), lowering glucose and waist thresholds, and rendering abdominal adiposity necessary for diagnosis. In Type 2 diabetic patients, IDF-defined MS has a lower prognostic value than Adult Treatment Panel III (ATP-III) criteria; this could depend either on lower thresholds for waist, or on the fact that adiposity was made necessary for diagnosis. METHODS: Information on 3-yr all-cause mortality of a consecutive series of 882 Caucasian Type 2 diabetic outpatients was obtained by the City of Florence Registry Office. Two different modifications of ATP-III criteria were tested: low waist threshold (LWT), with same threshold as IDF, but with abdominal adiposity not considered a necessary condition; and elevated waist as necessary condition (EWNC), with the older ATP-III threshold. RESULTS: Over the follow-up period, 115 (13.6%) deaths were recorded. A significantly higher mortality rate was observed in patients with LWT-, but not EWNC-defined MS, in comparison with the rest of the sample (14.2% vs 13.3%, p=0.705, and 14.7% vs 8.9%, p=0.050, for EWNC and LWT, respectively). Lowering the waist threshold did not reduce prognostic value in comparison with ATP-III definition of MS; conversely, when elevated waist circumference was considered a necessary condition for diagnosis, the predictive value for mortality decreased, irrespective of thresholds used. CONCLUSION: In Type 2 diabetic patients, modification of thresholds for waist circumference does not alter the prognostic value of MS. However, if abdominal adiposity is considered a necessary condition for diagnosis, the ability of MS to predict all-cause mortality is markedly reduced.

Metabolic syndrome and pulse pressure.

AIM: Pulse pressure (PP) has been reported to be increased in patients with abdominal adiposity and insulin resistance. Aim of the present study is to verify the association of high PP with metabolic syndrome (MS) and with its individual components. METHODS: The relationship between PP and MS was studied in a sample of 1724 subjects aged (mean +/- s.d.) 52.8 +/- 1.3 years, enrolled in a screening programme for diabetes FIrenze-Bango A Ripoli (FIBAR) study, and in a consecutive series of 1775 patients with type 2 diabetes aged 64.3 +/- 9.1 years; only subjects not treated with antihypertensive medication were included in the analysis. RESULTS: In the FIBAR sample, PP was significantly higher in subjects with MS. A significant correlation of PP was found in women with waist circumference, fasting glucose and triglyceride (r = 0.14, 0.15, and 0.09 respectively), and in men with fasting glucose only (r = 0.09); the correlation was no longer significant after adjustment for age and mean blood pressure. Similar results were obtained in the series of patients with type 2 diabetes. DISCUSSION: High PP is associated with MS and its components, but this association seems to disappear after adjustment for age and mean blood pressure. On the basis of the present data, high PP cannot be considered as one of the alterations associated with MS.

IDF and ATP-III definitions of metabolic syndrome in the prediction of all-cause mortality in type 2 diabetic patients.

AIM: The metabolic syndrome (MS) is associated with increased cardiovascular morbidity and mortality. Recently, the International Diabetes Federation (IDF) proposed to lower diagnostic thresholds for fasting glucose and waist circumference and to limit the diagnosis of MS only to subjects with abdominal adiposity. The aim of the present study was to assess the prognostic value of IDF criteria in diabetic patients, in comparison with previous ATP-III criteria. METHODS: An observational cohort study was performed on a consecutive series of 882 Caucasian type 2 diabetic outpatients, aged 65.3 +/- 10.9 years, with a duration of diabetes of 13.1 +/- 10.6 years. Information on 3-year all-cause mortality was obtained by the City of Florence Registry Office. RESULTS: The prevalence of MS was 68.4 and 73.7% using ATP-III and IDF criteria, respectively. Over the follow-up period, 115 (13.6%) deaths were recorded. Patients with ATP-III-defined MS showed a significantly higher mortality rate when compared with the rest of the sample (16.1% vs. 8.2%; p = 0.002), whereas a non-significant trend was observed using IDF classification (14.9% vs. 10.0%, p = 0.064). At Cox regression analysis, after adjustment for sex, age, and its individual components, diagnosis of MS with ATP-III criteria, but not with IDF criteria [OR (95% CI) 1.65 (0.99-2.72), p = 0.053], was significantly associated with higher mortality [OR (95%,CI) 2.38 [1.18-4.76]). CONCLUSION: In conclusion, in Caucasian type 2 diabetic patients the application of IDF criteria determines an increase of estimated prevalence of MS, without improving its prognostic value. Further studies are needed before the newer IDF criteria for MS are adopted on a larger scale.

Are sulphonylureas all the same? A cohort study on cardiovascular and cancer-related mortality.

BACKGROUND: Aim of the present study is the comparison of all-cause, cardiovascular and non-cardiovascular mortality, and cardiac morbidity, between patients treated with glibenclamide and gliclazide. METHODS: A retrospective observational cohort study was performed on a consecutive series of 568 outpatients (282 women, 286 men) with type 2 diabetes treated with either glibenclamide (n = 378) or gliclazide (n = 190). Information on all-cause mortality and on causes of death up to 31 December 2004 was obtained by the City of Florence Registry Office. Non-fatal cases requiring hospitalization were identified through the regional hospital discharge system using International Classification of Diseases. RESULTS: Mean follow-up was 5.0 +/- 1.6 and 4.4 +/- 2.0 years for death and cardiac events, respectively; during follow-up, 33 and 11 deaths were observed in the glibenclamide and gliclazide groups, with a yearly mortality rate of 4.3 and 2.2%, respectively (p < 0.05). At Cox regression, after adjustment for potential confounders, including comorbidity, glibenclamide treatment was associated with a significant increase in all-cause mortality [OR 2.1(1.2;2.7), p < 0.05], while the difference in cardiovascular mortality was not statistically significant after adjustment for age and sex. Mortality for malignancies was significantly higher in patients treated with glibenclamide after adjustment for age, sex, BMI, and insulin and metformin treatment, [OR 3.6(1.1;11.9); p < 0.05]. A higher incidence of cardiac events was associated with glibenclamide treatment only in patients with previously known ischaemic heart disease. CONCLUSIONS: Treatment with glibenclamide could be associated with higher mortality for cardiovascular diseases and malignancies, in comparison with gliclazide.

Fasting and post-prandial glycemia and their correlation with glycated hemoglobin in Type 2 diabetes.

OBJECTIVE: The relative contribution of fasting and post-prandial glucose to glycated hemoglobin (HbA1c) is controversial. In the present study, we assessed the relationship with HbA1c of fasting and post-prandial glucose measured in a more naturalistic setting, through home glucose self-monitoring or with a continuous glucose monitoring system (CGM). MATERIALS AND METHODS: A consecutive series of 300 patients with Type 2 diabetes were enrolled in the study, provided that they performed blood glucose self-monitoring. HbA1c and fasting plasma glucose (FPG) were measured at enrolment. RESULTS: Both fasting plasma and capillary glucose showed a significant correlation with HbA1c (r=0.66 and 0.61, respectively; p<0.001). When home glucose monitoring was considered, both mean fasting and post-prandial glucose showed a significant correlation with HbA1c (r=0.71 and 0.73, respectively). In patients in the lower tertile of body mass index (BMI), HbA1c showed a significant correlation at multivariate analysis with post-prandial glucose, but not with fasting glucose. In patients with HbA1c >7%, both fasting and post-prandial glucose showed a significant correlation, after adjustment for age and BMI, with HbA1c (both p<0.01); conversely, in those with HbA1c < or =7%, such a correlation could be observed for fasting (p<0.01), but not for post-prandial glucose. CONCLUSION: In conclusion, both fasting and post-prandial glucose contribute to the determination of HbA1c . Home glucose self-monitoring appears to provide a more accurate assessment of metabolic control than a single plasma glucose measurement in experimental conditions. Fasting glucose could provide a greater contribution to HbA1c in patients with lower HbA1c, while post-prandial glucose seems to play a major role in leaner Type 2 diabetic subjects.

Effect of diet and red wine consumption on serum total antioxidant capacity (TAC), dehydroepiandrosterone-sulphate (DHEAS) and insulin-like growth factor-1 (IGF-1) in Italian centenarians.

The traditional mediterranean diet is associated with a hope for longer survival. It has also been shown that the red wine possesses a protective effect against the oxidative stress. We studied TAC, the DHEAS and the IGF-1 in a group of 26 healthy centenarians, 17 women and 9 men, of the age range of 100--105 years. Furthermore, we analyzed also serum urate and bilirubin levels between drinkers and abstainers. Most of centenarian subjects have been moderate wine consumers (<500 ml/day of red wine). These subjects were subdivided as follows: (i) Group A: those who had maintained the style of their dietary habits as compared to the previous years (n=3 males, 10 females); (ii) Group B: those who actually consumed a diet being deficient compared to that of the previous years, but remained moderate drinkers of red wine (n=3 males, 4 females); and (iii) Group C: those who actually consumed a diet being deficient compared to that of the previous years, and at the same time, were abstainers in wine consumption (n=3 males, 3 females). The results show that in men three of the studied parameters decreased from Group A to C to considerable extents, as follows (mean+/-S.D.). TAC: 302.4+/-32.3; 142.0+/-24.1 and 96.4+/-20.1 micromol/l; DHEAS: 3.35+/-0.81; 2.52+/-0.18 and 1.34+/-0.14 micromol/l; IGF-1: 85.7+/-6.7; 76.6+/-6.7 and 65.6+/-2.6 ng/ml, respectively. For the same parameters, the results in the women were: TAC: 258.4+/-12.2; 182.1+/-14.0 and 107.6+/-10.0 micromol/l; DHEAS: 3.85+/-0.16; 2.34+/-0.19 and 2.05+/-0.04 micromol/l; IGF-1: 89.7+/-6.7; 76.6+/-4.7 and 64.2+/-2.7 ng/ml, respectively. We did not find any significant difference in the other serum parameters between drinkers (n=14) and abstainers (n=3) (urate: 267.6+/-52.9, and 289.5+/-80.1; bilirubin: 9.81+/-4.29 and 7.18+/-2.89 micromol/l, respectively). Our data suggest that the deteriorated diet caused a reduction of TAC, DHEAS and IGF-1 in the centenarians. However, red vine consumption exerted a protective effect against this trend, even if this protection is not reaching statistical significance in some cases (in men), which is due most probably to the lower number of male subjects in the study.

Upper gastrointestinal symptoms and therapies in elderly out-patients, users of non-selective NSAIDs or coxibs.

BACKGROUND: The association between coxib or non-steroidal anti-inflammatory drug use with gastrointestinal symptoms and drug prescriptions in ambulatory elderly patients is not well defined. AIM: To evaluate the association between non-steroidal anti-inflammatory drug NSAID and coxib use with gastrointestinal symptoms and therapies in elderly subjects managed by their general practitioner. MATERIALS: The study was carried out by 133 general practitioners in Italy. By using a structured interview, sex, age, physical function, current medications, new drug prescriptions and upper gastrointestinal symptoms were registered from all elderly subjects who were referred to their general practitioners during a 2-week period. The numbers of hospitalizations, gastrointestinal bleeding events and gastrointestinal diagnostic procedures occurring during the last 6-month period were recorded. RESULTS: Included in this study were 5515 elderly subjects. The overall prevalence of drug use was 92%. Musculo-skeletal drugs were taken by 15% of patients; NSAIDs were taken by 6%, and coxibs by 3% of patients. A significantly higher prevalence of upper gastrointestinal symptoms was observed in elderly NSAID users compared with coxib users and non-users of musculo-skeletal drugs (44% vs. 33% vs. 32% respectively, P = 0.001). The prescriptions of drugs for acid-related disorders were significantly higher in patients who were concomitantly taking NSAID rather than coxibs (13% vs. 6%, P < 0.01). The prescriptions of drugs for acid-related disorders were significantly associated with the presence of upper gastrointestinal symptoms (OR = 1.7, 95% CI = 1.6-1.9), previous gastrointestinal disorders (OR = 1.1, 95% CI = 1.0-1.3) and NSAID use (OR = 1.5, 95% CI = 1.0-2.2), but no coxib use. CONCLUSION: In this elderly population, upper gastrointestinal symptoms and prescriptions for gastroenterological drugs were higher in non-steroidal anti-inflammatory drug users than coxib users and non-users of musculo-skeletal drugs.

Healthy centenarian subjects: the effect of red wine consumption on liver function tests.

Liver function is well maintained with increasing age. The aim of our study was to investigate if long-term moderate (

Isolated ambulatory hypertension is common in outpatients referred to a hypertension centre.

The present investigation was aimed at determining the prevalence and the blood pressure (BP) profile of isolated ambulatory hypertension, defined as an elevated ambulatory BP with normal office blood pressure, in a series of 1488 consecutive outpatients referred for routine clinical evaluation of suspected or established arterial hypertension. All patients underwent both office BP (OBP) measurement by a physician and 24-h ambulatory blood pressure monitoring (ABPM). Using OBP values (cutoff for diagnosis of hypertension >/=140/90 mmHg) and daytime ABPM (cutoff for diagnosis of hypertension >/=135/85 mmHg), patients were classified into eight subgroups. In the whole series we found that, independent of treatment status, the prevalence of isolated ambulatory hypertension exceeded 10%. More importantly, 45.3% of individuals who presented with normal OBP values, showed elevated BP at ABPM. Night-time BP, 24-h pulse pressure, and BP variability were significantly higher in isolated ambulatory hypertensives than in normotensive or in white-coat hypertensive individuals. Therefore, isolated ambulatory hypertension is characterized by a blood pressure profile that is similar to that observed in sustained hypertension. These findings suggest that isolated ambulatory hypertension is very common and probably the indications for ABPM should be more extensive in outpatients referred to hypertensive centre.

Effectiveness and safety of cholinesterase inhibitors in elderly subjects with Alzheimer's disease: a "real world" study.

Clinical trials have demonstrated the efficacy of cholinesterase inhibitors (ChEI) in improving cognitive status and disability in subjects with mild to moderate Alzheimer's disease (AD). However, little is known about the effectiveness of ChEI in clinical practice, and no large clinical trials comparing different ChEI are available at present. Aim of this study was to evaluate safety and effectiveness of ChEI in a sample of elderly outpatients diagnosed with mild to moderate AD. We selected 407 subjects for ChEI treatment (donepezil,rivastigmine or galantamine). Their cognitive function was evaluated by means of the mini mental state examination (MMSE), and the global functional status was estimated by using the activities of daily living (ADL) and the instrumental activities of daily living (IADL) scales at baseline (To), then after 1 (T1), 3 (T2) and 9 months (T3), respectively. T3 follow-up was completed by 212 subjects. The patients were considered as responders (R), if the MMSEscore at T2 was unchanged or improved, if compared to that of T0. In 35 patients (8.6 %)treatment was withdrawn because of mostly gastrointestinal adverse events. Compared to the other drugs, donepezil was associated with a lower incidence of withdrawals due to adverse events. Subjects who completed T3 follow-up (age 78 +/- 6 years, MMSE scores 18.8 +/- 3.9) showed an increase at T2 of 0.7 +/- 2.7 (p = 0.001) and a decrease at T3 of -0.6 +/- 3.4 (p = 0.008) in the MMSE scores, as compared to To . The ADL and IADL scores did not show significant changes at T2; however, both decreased significantly at T3. The patients Rat-T2 showed a better cognitive and functional outcome at T3 , compared to the nonresponders(NR-at-T2), displaying values of MMSE R-at-T2 0.4 +/- 3.1 vs. NR-at-T2 -3.0 +/- 2.5, p = 0.001, and ADL values of -0.3 +/- 1.2 vs. -0.7 +/- 1.3, p = 0.03, respectively. No significant difference was found in the changes of MMSE scores between donepezil and rivastigmine (galantamine was not included in the comparison due to the small number of treated subjects). In conclusion, in this sample of elderly subjects with mild to moderate AD,treated with ChEI, a small but significant decline in cognitive and functional status was observed after 9 months. Subjects who showed a good response to treatment after 3 months, had a better cognitive and functional outcome at 9 months. No significant difference in cognitive outcome was found between drugs, while donepezil was better tolerated.

Epidemiological profile of symptomatic osteoarthritis in older adults: a population based study in Dicomano, Italy.

OBJECTIVES: To assess the prevalence of hand, hip, and knee osteoarthritis (OA) in an older Italian community dwelling population and its association with disability. METHOD: A cross sectional survey of the whole community aged 65 years and over, was carried out in Dicomano, a small rural town in Tuscany, Italy. Subjects were screened by geriatricians for major chronic conditions, including hip, knee, and hand OA, using diagnostic algorithms based on the American College of Rheumatology (ACR) clinical criteria. A rheumatologist examined subjects who screened positive. Disability was assessed by a World Health Organisation questionnaire. RESULTS: 697 of 864 eligible subjects (81% of the eligible population) were screened. OA of the knee, hand, or hip was identified by clinical ACR criteria respectively in 159, 139, and 81 subjects, and was confirmed by the rheumatologist in 158/182 (87%), 75/101 (74%), and 63.2% of cases. The estimated prevalence was 29.8%, 14.9%, and 7.7%, respectively. Only hip OA was significantly associated with disability in basic activities of daily living. CONCLUSIONS: About one third of community dwelling older people are affected by symptomatic peripheral OA. Hip OA was strongly associated with disability.

Cumulative effect of complete left bundle-branch block and chronic atrial fibrillation on 1-year mortality and hospitalization in patients with congestive heart failure. A report from the Italian network on congestive heart failure (in-CHF database).

BACKGROUND: Many clinical variables have been proposed as prognostic factors in patients with congestive heart failure. Among these, complete left bundle-branch block and atrial fibrillation are known to impair significantly left ventricular performance in patients with congestive heart failure. However, their combined effect on mortality has been poorly investigated. The aim of this study was to determine whether left bundle-branch block associated with atrial fibrillation had an independent, cumulative effect on mortality for congestive heart failure. METHODS AND RESULTS: We analysed the Italian Network on congestive heart failure (IN-CHF) Registry that was established by the Italian Association of Hospital Cardiologists in 1995. One-year follow-up data were available for 5517 patients. Complete left bundle-branch block and atrial fibrillation were associated in 185 (3.3%) patients. In this population the cause of congestive heart failure was dilated cardiomyopathy (38.4%), ischaemic heart disease (35.1%), hypertensive heart disease (17.3%), and other aetiologies (9.2%). This combination of electrical defects was associated with an increased 1-year mortality from any cause (hazard ratio, HR: 1.88; 95% CI 1.37-2.57) and sudden death (HR: 1.89; 95% CI 1.17-3.03) and 1-year hospitalization rate (HR: 1.83; 95% CI 1.26-2.67). CONCLUSIONS: In patients with congestive heart failure, the contemporary presence of left bundle-branch block and atrial fibrillation was associated with a significant increase in mortality. This synergistic effect remained significant after adjusting for clinical variables usually associated with advanced heart failure. We can conclude that this combination of electrical disturbances identifies a congestive heart failure specific population with a high risk of mortality.

Features of excessive alcohol drinking in older adults distinctively captured by behavioral and biological screening instruments. An epidemiological study.

The entire > or =65-year-old population living in a small Italian town, where alcohol use is almost ubiquitous, was assessed with a frequency-quantity questionnaire for alcohol intake and with two screening instruments for alcohol problems, the CAGE questionnaire and the MCV-gammaGT test. Aim of the study was to assess whether these instruments identify different subsets of subjects with alcohol problems. Of the 649 participants, 19.1% were at-risk drinkers (average intake > 40 g/day in men and > 20 g/day in women). Both the screening instruments were positive in only a minority of participants. Of the 377 drinkers, 53 gave > or =1 affirmative response to the CAGE questionnaire, whereas 24 had a positive MCV-gammaGT test. The concordance between positive CAGE questionnaire and MCV-gammaGT test was limited to seven subjects (kappa = 0.10), and these tests identified subjects who differed for several health and psychosocial characteristics. Participants aged > or =75 years drank less, but had similar prevalence of CAGE and MCV-gammaGT positive markers as compared to younger participants. In conclusion, excessive drinking is common in the elderly. Screening tests based on behavioral and biological markers identify two different sets of subjects with possible alcohol problems. This might indicate the opportunity to use these instruments in conjunction.