Is ankle/arm pressure predictive for cardiovascular mortality in older patients living in nursing homes?

AIM: To identify whether Ankle/Arm Index (AAI) is a predictive factor for cardiovascular mortality in institutionalised elderly. DESIGN: longitudinal descriptive study. SETTING: 2 large nursing homes in Turin, Italy. SUBJECTS: 418 dependent elderly (83 males, 335 females, mean age 83.7+/-8.5 y, range 55-102) living in the nursing homes. MEASUREMENTS: the prevalence of peripheral arterial disease (PAD) was evaluated using a Doppler Ultrasound measurement of AAI (Ankle/Arm blood pressure Index). Death causes according to ICD-9-CM were ascertained on patient's clinical records. RESULTS: Diagnosis of PAD was made in 122 subjects (29.2%) with AAI <0.90. After a 3 year follow-up 203 patients (48.6%) died. The presence of PAD was not related to total mortality or to mortality for ischemic heart disease (IHD), cerebrovascular disease or other causes. IHD mortality was significantly and independently related to low haemoglobin values, previous cerebrovascular disease, polypharmacy and poor mobility conditions. CONCLUSION: The prevalence of PAD is high in nursing home residents. AAI is not predictive for IHD mortality in this population. In very frail elderly traditional risk factors and PAD are less important predictors of death compared to poor functional status, nutritional factors and previous cardiovascular disease.

[Sleep disorders in the aged]. / I disturbi del sonno in età avanzata.

OBJECTIVES: The aim of the study was the assessment of prevalence and risk factors of sleep disorders in the elderly. METHODS: The study sample consisted of a group of institutionalized elderly, from two university affiliated community nursing homes in Turin. The following subjects were excluded: a) those aged less than 65 years; b) had length of stay less than thirty days; c) were not able to communicate because of severe aphasia or severe hearing loss and d) had cognitive impairment based on the Short Portable Mental Status Questionnaire (SPMSQ ) > 5. A total of 88 subjects (65-102 ys; 24 male and 64 female) have been studied. Comorbidity was measured using the Acute Physiology and Chronic Health Evaluation scale (APACHE), disability using the index of Activity Daily Living (ADL), depressive symptoms using the Geriatric Depression Scale (GDS); sleep quality was determined using the Pittsburgh Sleep Quality Index (PSQI) and the subjective health by the Self-Rated Health (SRH) was also evaluated. RESULTS: Using the PSQI questionnaire, 70 subjects (79.5%) were identified as "poor sleepers" (PSQI > 5). They complained of difficulties in getting sleep (85.7%) and frequent awakening (75.7%). The most common causes of sleep disturbances were nycturia (51.4%), cough (38.6%) and pain (32.9%). Insomnia correlated with depressive symptoms, poor physical activity, number of medications and bad self-rated health. CONCLUSION: Sleep disorders probably are due to physical, psychological or ambient factors. The identification and correction of treatable causes of insomnia are relevant for improving the quality of sleep and health in the elderly.

[Deep venous thrombosis and cancer in the elderly]. / La trombosi venosa profonda nell'anziano talora marker tumorale.

BACKGROUND: The aim of this study was the assessment of Deep Venous Thrombosis (DVT), and its relationship with malignant neoplasm in elderly. METHODS: The study sample included six-hundred patients admitted to the University Department of Geriatric Medicine in Turin in 1997 (332 male and 268 female, mean age 77.7+/-8 year). Not-neoplastic subjects affected with DVT were followed up for two years. We analysed incidence of malignant cancer in this group and then it was compared with incidence of new neoplasm in subjects without DVT at baseline. RESULTS: Prevalence of deep venous thrombosis at hospital admission and during the hospitalization was 4.8%. About 50% of patients with DVT had a related neoplastic disease. Patients with DVT were affected with malignant disease four times more than subjects without DVT. The risk of a neoplasm, during the two-years follow-up, was 6.8 times higher for patients with DVT at baseline in comparison with elderly without DVT. We didn't find significative differences between subjects with primary DVT and elderly with DVT due to neoplasm. CONCLUSIONS: There is a wide association between DVT and malignant disease. For this reason a careful follow-up of people with DVT is recommended.

[Factors predicting a prolonged hospital stay in elderly patients]. / Fattori determinanti il protrarsi del ricovero nel paziente anziano.

BACKGROUND: Aim of our prospective study was to evaluate risk factors for prolonged hospitalization in elderly patients. METHODS: The study sample included 1054 patients admitted to University Department of Geriatric Medicine in Turin, Italy. We analysed: demographic variables (age, sex, marital status, economic status and living condition), affective status (GDS), cognitive status (SPMSQ), functional status (ADL-IADL), medical dependence (DMI), medical diagnosis, systolic and diastolic blood pressure, some haematological parameters (haemoglobin, creatinine, albumin, sodium, potassium). RESULTS: Average length of stays was 18+/-20.6 days; 178 patients died during hospitalization and their length of stay significantly longer (21.8+/-25.59) than survivors (17.4+/-19.3). We find that DMI dependence, impaired IADL and ADL score were associated with longer hospital stays. Medical diagnosis related to a prolonged hospitalization were: neoplasm, chronic bronchitis, hip fracture and peripheral arterial disease (PAD) with critical ischemia. Longer hospitalisation was associated also with high level of creatinine and low level of albumin and sodium. Indipendent predictors variables of prolonged hospital stay were: ADL impairment, pressure sores, hip fractures, PAD with critical ischemia, low sodium value. CONCLUSIONS: Multidimensional assessment among hospitalized elderly allows to identify risk factors for prolonged hospital stay.

[The dependence medical index (DMI): validation and comparison with the activity daily living and the instrumental activity daily living]. / L'indice medico di non autosufficienza: validazione e comparazione con le scale ADL e IADL.

AIM: The aim of this study was the validation of the dependence medical index (DMI), a disability medical assessment tool in the elderly. METHODS: Study sample included 1054 subjects aged 65 and over, consecutively admitted to the University Department of Geriatric Medicine of Turin, Italy. A total of 356 of these subjects was classified as dependent to activity of daily living (ADL) and instrumental activity of daily living (IADL) scales. Some conditions causing medical dependence were detected, such as strength and/or motility impairment, incontinence, pressure sores, disturbances in speech and communication, decline in sight and/or hearing, terminal illness (death expected within 6 months), need for multiple and complex therapies, episodic disorientation, dizziness with tendency to fall, use of the wheel-chair. The relationship between dependence and the DMI was studied by discriminant analysis. A scale was created using the discriminant scores of each 15 medical indications for disability. RESULTS: The discriminant model of DMI was validated by cross-validation statistical method: its application permitted to classify correctly 73.1% of the sample. The DMI permitted to classify the dependent subjects in variable percentages: from 67% (DMI score > or =1) to 90% (DMI score > or =7). The best ratio between specificity and sensibility was for score 4 to DMI. CONCLUSION: The conclusion is drawn that DMI can be used to detect and evaluate the disability for medical reasons in elderly people.

[Predictive variables of mortality in elderly patients after hospitalization. Significance of multidimensional evaluation]. / Variabili predittive di mortalità negli anziani dopo il ricovero ospedaliero. L'importanza della valutazione multidimensionale.

Functional status evaluation in the elderly is stronger predictor of hospital outcomes than type and number of pathology. Multidimensional and functional assessment among hospitalized elderly allows to identify, as well as acute and chronic illness, disabilities of sanitary problems and socio-economical aspects that in the elderly can complicate illness. Our study has identified six-month mortality post hospitalization of 20.2%. The high mortality observed in our follow-up agrees with the literature and it is a marker of considerable frailty among elderly patients. The independent predictor variables of six month post hospital mortality in the study were: male gender, dependence DMI score, low serum albumin (2.8 g/dl), impaired IADL score, cancer illness and APACHE score < 13.7. These measures represent distinct domains: demographic, functional and clinical. Identifying predictors of high-risk patients is an important way in accurate targeting.