Chronic obstructive pulmonary disease and long-term mortality in elderly subjects with chronic heart failure.

BACKGROUND: Chronic heart failure (CHF) and chronic obstructive pulmonary disease (COPD) are associated with high rates of mortality in elderly subjects. Concurrent CHF and COPD frequently occur, especially in with advancing age. This study examines long-term mortality in community-dwelling elderly subjects affected by CHF alone, COPD alone, and coexistent CHF and COPD. METHODS: The study evaluated 12-years mortality in 1288 subjects stratified for the presence or absence of CHF or COPD alone, and for coexistence of CHF and COPD. RESULTS: Mortality, at 12 year follow-up, was 46.7% overall, 68.6% in the presence of CHF alone (p < 0.001), 56.9% in the presence of COPD alone (p < 0.01); mortality was 86.2% where CHF and COPD coexisted (p < 0.001) and was significantly higher than in CHF or COPD alone (p < 0.05). Multivariate analysis indicates that CHF (Hazard risk = 1.67, 95% confidence interval 1.15-3.27, p < 0.031) and COPD (Hazard risk = 1.27, 95% confidence interval = 1.08-1.85, p < 0.042) were predictive of long-term mortality. When CHF and COPD simultaneously occurred, the risk dramatically increased up to 3.73 (95% confidence interval = 1.19-6.93, p < 0.001). CONCLUSIONS: Long-term follow-up showed higher mortality among elderly subjects affected by CHF or COPD. Simultaneous presence of CHF and COPD significantly increased the risk of death. Therefore, the presence of COPD in CHF patients should be considered a relevant factor in predicting high risk of mortality.

Long-term mortality in frail elderly subjects with osteoarthritis.

OBJECTIVE: Elderly subjects are characterized by a high prevalence of OA and clinical frailty. This study aimed to examine the predictive role of clinical frailty on long-term mortality in elderly subjects with and without OA. METHODS: Mortality was evaluated after a 12-year follow-up in 698 subjects with and 590 subjects without OA recruited in 1992. Clinical frailty was assessed according to the Frailty Staging System and stratified in tertiles. RESULTS: After a 12-year follow-up, mortality was 42.2% in subjects without and 55.8% in subjects with OA (P = 0.256). With increasing frailty, mortality increased by 30.5% (P for trend < 0.001) in subjects without and by 45.6% in subjects with OA (P for trend < 0.001). Multivariate analysis showed that frailty [hazard ratio (HR) = 1.49 for each unit of increase, 95% CI 1.32, 1.94, P < 0.001) but not OA (HR = 1.28, 95% CI 0.987, 1.39, P = 0.412) was predictive of long-term mortality. Moreover, when Cox regression analysis was performed, frailty enhanced the risk of long-term mortality for each unit of increase by 32% (HR = 1.32, 95% CI 1.06, 1.65, P = 0.03) in the absence of OA and by 98% in the presence (HR = 1.98, 95% CI 1.63, 2.95, P < 0.01) of OA. CONCLUSION: Clinical frailty significantly predicts mortality in subjects without OA and even more in those with OA. Thus clinical frailty may be considered a new prognostic factor to identify subjects with OA at high risk of mortality.

Determinants of prolonged intensive care unit stay after cardiac surgery in the elderly.

OBJECTIVES: In the last decade, there has been a rapid increase in the number of elderly patients referred for cardiac surgery. Recent studies have identified risk factors for prolonged intensive care unit (ICU) stay in cardiac surgery patients. The aims of this study was to evaluate pre-operative risk factors for ICU stay longer than 3 days in a cardiac surgery elderly population, and whether prolonged ICU stay may influence disability, functional recovery and length of rehabilitation. METHODS: Two hundred and fifty elderly (≥65 years) cardiac surgery patients were consecutively evaluated at enter in cardiac rehabilitation after ICU dismissal from January 2008 to July 2009. Univariate and multivariate analyses for risk factors were performed for ICU stay longer than 3 days. Thereafter, 6-minute walking test (6MWT), Barthel Index (BI), BI percent recovery and length of stay (LOS) in rehabilitation were evaluated. RESULTS: Mean age was 72.9±4.8 yrs, 170 (68%) patients underwent cardiac surgery for coronary artery by-pass grafting (CABG), 56 (22.4%) for valve replacement and 24 (9.6%) for both CABG and valve replacement. Mean ICU stay was 1.9±1.5 days and 72 patients (28.8%) spent more than 3 days in ICU. Age, New York Heart Association class ≥3, Cumulative Illness Rating Scale (CIRS) score, prevalence of stroke and renal failure were significantly higher in patients with than in those without ICU stay ≥3 days. Off-pump CABG, Physical Activity Scale for the Elderly (PASE), BI and 6MWT were significantly lower in patients with than in those without ICU stay ≥3 days. Multivariate analysis shows that female sex, a NYHA class ≥3, CIRS and PASE score are predictors of ICU stay ≥3 days independently of age, off-pump CABG, stroke and renal failure. Multiple linear regression shows that ICU stay ≥3 days is negatively associated with 6MWT, BI at entry and BI percent recovery, whereas it is positively associated with a longer rehabilitation LOS. CONCLUSIONS: Pre-operative comprehensive assessment in the elderly could help to identify predictors of long ICU stay after cardiac surgery. This approach could help to better define the elderly cardiac surgery patients and their needs throughout the cardiac rehabilitation program in order to maximize functional capacity recovery, reducing disability and rehabilitation LOS.

Depressive symptoms predict mortality in elderly subjects with chronic heart failure.

BACKGROUND: Chronic heart failure (CHF) is characterized by a high mortality in the elderly. Moreover, depression status is also related to poor prognosis in advancing age. Thus, we sought to determine whether depressive status predicts long-term mortality in subject with or without CHF. METHODS AND RESULTS: Long-term mortality after 12-year follow-up in 125 elderly subjects with CHF and 1143 elderly subjects without CHF was studied. Depression was evaluated using the Geriatric Depression Scale (GDS), and all subjects were stratified in tertiles according to GDS score (0-10, 11-20 and 21-30). With increasing GDS score, long-term mortality at the end of follow-up increased from 43·4% to 72·0% in subjects without (P < 0·001) and from 52·6% to 83·9% in subjects with (P < 0·007) CHF. In multivariate analysis, GDS appeared to be predictive of long-term mortality in the absence (Hazard ratio = 1·01; confidence interval 95% 1·00-1·05; P = 0·04) and, even more, in the presence of CHF (Hazard ratio = 1·08; confidence interval 95% 1·01-1·15; P < 0·01). CONCLUSIONS: Depression symptoms predict long-term mortality in elderly subjects without and, even more, with CHF. Thus, depression can be considered a strong predictor of death in CHF elderly subjects.

Joint effect of physical activity and body mass index on mortality for acute myocardial infarction in the elderly: role of preinfarction angina as equivalent of ischemic preconditioning.

BACKGROUND: Preinfarction angina (PrA), clinical equivalent of ischemic preconditioning, confers protection against in-hospital mortality for acute myocardial infarction (AMI) in adult but not in elderly patients. This study aims to examine the interaction between physical activity and body mass index (BMI) in preserving the cardioprotective effect of PrA in elderly patients with AMI. DESIGN: Elderly patients (>/=65 years old) with AMI admitted to Coronary Care Unit. METHODS: Elderly patients with AMI were retrospectively stratified for the presence and absence of PrA, and for quartiles of BMI and physical activity. In-hospital outcomes (death, cardiogenic shock, and reinfarction and creatine kinase-MB peak) were evaluated. RESULTS: In-hospital mortality of 1014 elderly patients with AMI was 19.2% in those with PrA and 22.7% in those without (P=0.18, NS). Mortality further decreased with increased physical activity and reduced BMI, a trend that was not observed in patients without PrA. When physical activity and BMI were considered together, lowest in-hospital mortality was observed in patients with highest physical activity and normal BMI (from 18.2 to 9.6%; P<0.01) with the greatest reduction observed in patients with PrA (from 18.3 to 5.1%; P=0.02). Multivariate analysis showed that PrA did not exert a protective effect in all patients irrespective of physical activity and BMI. A protective role was, however, observed in patients with highest physical activity or normal BMI and reached a maximum protective role in patients who showed both highest physical activity and normal BMI [odds ratio=0.08; 95% confidence interval=0.02-0.72; P<0.01]. CONCLUSION: The cardioprotective effect of PrA was preserved in elderly patients who showed the highest physical activity and a normal BMI.

Charlson Comorbidity Index does not predict long-term mortality in elderly subjects with chronic heart failure.

BACKGROUND: comorbidity plays a critical role in the high mortality for chronic heart failure (CHF) in the elderly. Charlson Comorbidity Index (CCI) is the most extensively studied comorbidity index. No studies are available on the ability of CCI to predict mortality in CHF elderly subjects. The aim of the present study was to assess if CCI was able to predict long-term mortality in a random sample of elderly CHF subjects. METHODS: long-term mortality after 12-year follow-up in 125 subjects with CHF and 1,143 subjects without CHF was studied. Comorbidity was evaluated using CCI. FINDINGS: in elderly subjects stratified for CCI (1-3 and > or =4), mortality was higher in non-CHF subjects with CCI > or =4 (52.4% versus 70%, P < 0.002) but not in those with CHF (75.9% versus 77.6%, P = 0.498, NS). Cox regression analysis on 12 years mortality indicated that both CCI (HR = 1.15; 95% CI = 1.01-1.31; P = 0.035) and CHF (HR = 1.27; 95% CI = 1.04-8.83; P = 0.003) were predictive of mortality. When Cox analysis was performed by selecting the presence and the absence of CHF, CCI was predictive of mortality in the absence but not in the presence of CHF. CONCLUSION: CCI does not predict long-term mortality in elderly subjects with CHF.

Transient ischemic attack before nonlacunar ischemic stroke in the elderly.

BACKGROUND: Several studies suggest transient ischemic attack (TIA) may be neuroprotective against ischemic stroke analogous to preinfarction angina's protection against acute myocardial infarction. However, this protective ischemic preconditioning-like effect may not be present in all ages, especially among the elderly. The purpose of this study was to determine the neuroprotective effect of TIAs (clinical equivalent of cerebral ischemic preconditioning) to neurologic damage after cerebral ischemic injury in patients over 65 years of age. METHODS: We reviewed the medical charts of patients with ischemic stroke for presence of TIAs within 72 hours before stroke onset. Stroke severity was evaluated by the National Institutes of Health Stroke Scale and disability by a modified Rankin scale. RESULTS: We evaluated 203 patients (>or=65 years) with diagnosis of acute ischemic stroke and categorized them according to the presence (n = 42, 21%) or absence (n = 161, 79%) of TIAs within 72 hours of stroke onset. Patients were monitored until discharged from the hospital (length of hospital stay 14.5 +/- 4.8 days). No significant differences in the National Institutes of Health Stroke Scale and modified Rankin scale scores were observed between those patients with TIAs and those without TIAs present before stroke onset at admission or discharge. CONCLUSION: These results suggest that the neuroprotective mechanism of cerebral ischemic preconditioning may not be present or functional in the elderly.

Lifestyle and prevention of cardiovascular disease in the elderly: an Italian perspective.

The life span of human beings is partially influenced by genetic factors, but outcomes of aging are profoundly influenced by lifestyle and other environmental factors. Age-related modifications of the cardiovascular system are preserved by antiaging lifestyle interventions such as physical activity and caloric restriction. Accordingly, physical activity and low body mass index reduce mortality in older men with cardiovascular diseases. Several mechanisms have been proposed to explain the protective effect of lifestyle interventions against cardiovascular diseases in the elderly, including a reduction of vulnerability (i.e., the age-related reduction of endogenous mechanisms protective against pathologic insults). The age-related reduction of ischemic preconditioning, the most powerful endogenous protective mechanism against myocardial ischemia, is restored by both physical activity and caloric restriction. Thus, older persons can implement lifestyle practices that minimize their risk of death from cardiovascular diseases.

Echocardiographic evaluation of left ventricular end-systolic elastance in the elderly.

BACKGROUND: The aging heart is characterized by structural changes, which are implicated in the development of left ventricular diastolic dysfunction. However, important changes in systolic function may also occur. Left ventricular end-systolic elastance (E(es)) is a major determinant of cardiac systolic function and ventricular-arterial interaction. AIM: To evaluate left-ventricular E(es) in elderly subjects compared with adult control subjects. METHODS: We studied dilated (DA, n=14) and hypertensive (HA, n=21) cardiomyopathy patients, and both adult control (A, n=25; age 55.6+/-6.6 years) and elderly (E, n=25; age 76.3+/-7.1 years) subjects without clinical-instrumental evidence of cardiovascular disease. M-mode, two-dimensional, and pulsed Doppler echocardiogram were performed. Doppler-derived indices of diastolic function were assessed and E(es) was calculated by a modified single-beat method. RESULTS: E(es) was reduced in dilated cardiomyopathy (1.32+/-0.10 mm Hg/ml) and increased in hypertensive cardiomyopathy (3.12+/-0.33 mm Hg/ml) patients compared to age-matched control subjects (1.96+/-0.26 mm Hg/ml; p<0.01 and p<0.05, respectively). More importantly, E(es) was higher in the elderly (2.52+/-0.70 mm Hg/ml) than in the adult control group (p<0.05) and was linearly correlated with age (r2=0.639; p<0.0001). CONCLUSION: Age-related increase in E(es), together with diastolic dysfunction, may lead to aging heart decompensation.

Atenolol use is associated with long-term mortality in community-dwelling older adults with hypertension.

AIM: The role of atenolol, a non-vasodilating beta-blocker drug, on long-term mortality in hypertensive older adults is still unclear. The aim of the present study was to evaluate long-term mortality in community-dwelling hypertensive older adults taking atenolol. METHODS: Long-term mortality after 12-year follow up in isolated hypertensive older adults (n = 972) was analyzed. The patients were stratified in the presence and absence of atenolol use. Systolic, diastolic and pulse arterial pressure were measured. RESULTS: Older adults taking atenolol showed a greater mortality and higher pulse arterial pressure values than those not taking atenolol (73.9% vs 55.0%; P = 0.047 and 74.7 ± 14.1 vs 63.0 ± 14.2 mmHg, P < 0.001, respectively). Cox regression analysis showed that atenolol use (hazard risk 1.91; 95% confidence interval 1.04-4.31; P = 0.04) and pulse arterial pressure (hazard risk 1.02; 95% confidence interval 1.01-1.03; P = 0.032) were predictive of long-term mortality. CONCLUSIONS: Atenolol use was related to increased mortality in community-dwelling hypertensive Older adults. This increase in mortality risk seems to be related to an increase of pulse arterial pressure.

Clinical frailty and long-term mortality in elderly subjects with diabetes.

Elderly subjects are characterized by a high prevalence of diabetes and clinical frailty. This study aimed to examine the predictive role of clinical frailty on long-term mortality in elderly subjects with and without diabetes. The study evaluated mortality after 12-year follow-up in 188 subjects with diabetes and 1,100 subjects without diabetes selected in 1992. Clinical frailty was assessed according to the "Frailty Staging System" and stratified in tertiles. After 12-year follow-up, mortality was 50.5 % in subjects without and 66.5 % in subjects with diabetes (p < 0.001). With increasing frailty, mortality increases from 57.9 to 79.0 % (p for trend <0.01) in subjects without and from 75.9 to 87.0 % in subjects with diabetes (p for trend <0.001). Multivariate analysis shows that both diabetes (hazard ratio = 1.38; 95 % confidence interval = 1.12-1.95; p = 0.02) and frailty score (hazard ratio = 1.58 for each unit of increase; 95 % confidence interval = 1.41-2.35; p = 0.04) are predictive of long-term mortality. Moreover, when Cox regression analysis was performed by selecting sex, frailty increases the risk of long-term mortality for each unit of increase by 14 % (hazard ratio = 1.14; 95 % confidence interval = 1.10-1.18; p < 0.01) in women and by 60 % in men (hazard ratio = 1.60; 95 % confidence interval = 1.21-2.12; p < 0.001) in the absence and by 31 % (Hazard ratio = 1.31, 95 % confidence interval = 1.03-1.85, p = 0.03) in women and by 60 % in men (hazard ratio = 1.99, 95 % confidence interval = 1.75-3.05, p < 0.001) in the presence of diabetes, respectively. We concluded that diabetes predicts long-term mortality in elderly subjects. Moreover, clinical frailty significantly predicts mortality in subjects without and even more in those with diabetes. This phenomenon is particularly evident in men. Thus, clinical frailty may be considered a new prognostic factor to identify subjects with diabetes at high risk of mortality.

Six-minute walking test but not ejection fraction predicts mortality in elderly patients undergoing cardiac rehabilitation following coronary artery bypass grafting.

BACKGROUND: Age-related effects on the ability of 6-min walking test (6MWT) and ejection fraction (EF) to predict mortality in coronary artery bypass grafting (CABG) patients undergoing cardiac rehabilitation (CR) is still debated. DESIGN AND METHODS: In order to verify the role of 6MWT and EF on all-cause mortality in patients undergoing CR following CABG, 882 CABG patients undergoing CR stratified in adults (<65 years) and elderly (≥65 years) were studied. RESULTS: At the admission, EF was 52.6 ± 9.1% in adults and 51.3 ± 8.9% in elderly (p = 0.234, NS) while 6MWT was 343.8 ± 93.5 m in adults and 258.9 ± 95.7 m in elderly (p < 0.001). After 42.9 ± 14.1 months follow up, mortality was 8.2% in adults and 10.9% in elderly (p = 0.176, NS). Cox regression analysis shows that EF ≥ 50% and 6MWT ≥300 m are protective on mortality in all CABG patients before CR. However, EF ≥50% in adults (HR 0.18, 95% CI 0.06-0.49, p < 0.005) but not in elderly (HR 1.16, 95% CI 0.45-3.42, p = 0.354, NS) and 6MWT ≥300 m in elderly (HR 0.34, 95% CI 0.10-0.79, p = 0.033) but not in adults (HR 0.76, 95% CI 0.31-2.12, p = 0.654, NS) exert a protective role on mortality. CONCLUSIONS: Our results indicate that both EF ≥ 50% and 6MWT ≥ 300 m independently protect against mortality in CABG patients before CR. However, their protective role is age dependent. In fact, EF ≥ 50% is protective in adults but not in elderly while 6MWT ≥ 300 m is protective in elderly but not in adult patients.

Role of permanent atrial fibrillation (AF) on long-term mortality in community-dwelling elderly people with and without chronic heart failure (CHF).

Permanent AF is characterized by an increased mortality in elderly subjects with CHF. Moreover, AF increased the risk of mortality also in elderly subjects without CHF. Thus, we examined long-term mortality in community-dwelling elderly people with and without CHF. A total of 1332 subjects aged 65 and older were selected from the electoral rolls of Campania, a region of southern Italy. The relationship between AF and mortality during a 12-year follow-up in 125 subjects with CHF and in 1.143 subjects without CHF were studied. Elderly subjects showed a higher mortality in those with respect to those without AF (72.1% vs. 51.8%; p<0.01). Similarly, elderly subjects without CHF showed a higher mortality in those with respect to those without AF (61.8% vs. 49.8%; p<0.05). In contrast, elderly subjects with CHF showed a similar mortality in those with respect to those without AF (74.7% vs. 82.4%; p=0.234). Multivariate analysis shows that AF was predictive of mortality in all elderly subjects (Hazard Risk=HR=1.39, 95% confidence interval (CI)=1.25-2.82; p<0.001). When the analysis was conducted considering the presence and the absence of CHF, AF was strongly predictive of mortality in elderly subjects without CHF (HR=1.95, 95%CI=1.25-4.51; p<0.001) but not in those with CHF (HR=1.12, 95%CI=0.97-3.69; p=0.321). We concluded that AF is able to predict long-term mortality in elderly subjects. Moreover, AF is strongly predictive of long-term mortality in the absence but not in the presence of CHF.

Association between nocturia and falls-related long-term mortality risk in the elderly.

OBJECTIVES: A high falls-related mortality rate in the elderly is not exclusively related to injuries. Moreover, the risk of falls increases with urinary disorders such as nocturia. The aim of this study was to investigate the role of nocturia in falls-related long-term mortality in elderly subjects. DESIGN: Longitudinal study. SETTING AND PARTICIPANTS: The "Osservatorio Geriatrico Regione Campania" was a cross-sectional study performed in 1992 in Campania, a region of Southern Italy. MAIN MEASUREMENTS: Long-term mortality (12 years' follow-up) in 178 elderly subjects (mean age 74.0 ± 6.3 years) with falls and 1110 elderly subjects (mean age 75.2 ± 6.4 years) without falls at baseline was measured. Subjects were then stratified for the presence/absence of nocturia. KEY RESULTS: In our sample, the prevalence of falls was 13.8% and the prevalence of nocturia was 45.7%. Long-term mortality was 51.3% in nonfallers and 62.9% in fallers (P < .05). In the absence of nocturia, long-term mortality was similar in nonfallers and fallers (49.0% vs 46.7%; P = .514, NS). In contrast, in the presence of nocturia, long-term mortality was higher in fallers than in nonfallers (74.5% vs 53.6%; P < .05). Cox regression analysis confirmed the predictive role of falls on long-term mortality in the presence of nocturia (hazard ratio 60; 95% confidence interval 1.01-2.57; P < .05) but not in the absence of nocturia (hazard ratio = 1.27; 95% confidence interval 0.81-1.99; P = .28). CONCLUSIONS: Our data suggest that falls are related to an increased risk of long-term mortality in the elderly much more in the presence of nocturia. This phenomenon is probably related to the high comorbidity that usually affects elderly subjects with nocturia.

Role of clinical frailty on long-term mortality of elderly subjects with and without chronic obstructive pulmonary disease.

BACKGROUND AND AIMS: Elderly subjects are characterized by a high prevalence of chronic obstructive pulmonary disease (COPD) and frailty. This study examined the predictive role of frailty on long-term mortality in elderly subjects with and without COPD. METHODS: The study assessed mortality after a 12-year follow-up in 489 subjects with COPD and 799 subjects without COPD, selected in 1992. Frailty was assessed according to the Frailty Staging System scores ranging from 1 to 7. RESULTS: After 12 years' follow-up, mortality was 48.1% in subjects without and 60.7% in subjects with COPD (p<0.001). With increasing frailty, mortality increased from 41.7% to 75.1% (p for trend <0.01) in subjects without and from 54.3% to 97.0% in subjects with COPD (p for trend <0.001). Multivariate analysis showed that both COPD [hazard ratio (HR)=1.34; 95% confidence interval (95% CI)=1.02-1.81; p=0.042] and frailty score (HR=1.69 for each unit of increase; 95% CI=1.42- 2.00; p<0.001) were predictive of long-term mortality. The frailty score also increased the risk of long-term mortality by 34% in the absence of COPD (HR=1.34 for each unit of increase; 95% CI=1.02-1.81; p<0.05) and by 80% in its presence (HR=1.80 for each unit of increase; 95% CI=1.28-2.53; p<0.001). CONCLUSIONS: Long-term mortality was higher in elderly subjects with than in those without COPD. The clinical frailty score also significantly predicted mortality in subjects without and, even more, in those with COPD. Thus, clinical frailty may be considered a new prognostic factor to identify COPD subjects at high risk of mortality.

Waist circumference but not body mass index predicts long-term mortality in elderly subjects with chronic heart failure.

OBJECTIVES: To examine whether waist circumference (WC) and body-mass index (BMI) can predict long-term mortality in elderly subjects with and without chronic heart failure (CHF). DESIGN: Longitudinal evaluation with a 12-year follow-up. SETTING: Campania, a region of southern Italy. PARTICIPANTS: One thousand three hundred thirty-two subjects aged 65 and older selected from the electoral rolls of Campania. MEASUREMENTS: The relationship between WC or BMI and mortality during a 12-year follow-up in 125 subjects with and 1,143 subjects without CHF. RESULTS: Mortality increased as WC increased in elderly subjects without CHF (from 47.8% to 56.7%, P=.01), and the increase was even greater in patients with CHF (from 58.1% to 82.0%, P=.01). In contrast, mortality decreased as BMI increased in elderly subjects without CHF (from 53.8% to 46.1%, P0=.046) but not in those with CHF. According to Cox regression analysis, BMI protected against long-term mortality in the absence but not in the presence of CHF. In the absence of CHF, WC was associated with a 2% increased risk of long-term mortality for each 1-cm greater WC (Hazard Ratio (HR)=1.02, 95% confidence interval (CI)=1.01-1.03; P<.001), versus 5% increased in the presence of CHF (HR=1.06, 95% CI=1.02-1.10; P<.001). CONCLUSION: WC, but not BMI, is predictive of long-term mortality in elderly individuals with CHF and to a lesser extent in those without CHF.

Social support and long-term mortality in the elderly: role of comorbidity.

Several studies have demonstrated a global increase in morbidity and mortality in elderly subjects with low social support or high comorbidity. However, the relationship between social support and comorbidity on long-term mortality in elderly people is not yet known. Thus, the present study was performed to evaluate the relationship between social support and comorbidity on 12-year mortality of elderly people. A random sample of 1288 subjects aged 65-95 years interviewed in 1992 was studied. Comorbidity by Charlson Comorbidity Index (CCI) score and Social Support by a scale in which total score ranges from 0 to 17, assigning to lowest social support the highest score, were evaluated. At 12-year follow-up, mortality progressively increase with low social support and comorbidity increasing (from 41.5% to 66.7% and from 41.2% to 68.3%, respectively; p<0.001). Moreover, low social support progressively increases with comorbidity increasing (and 12.4±2.5 to 14.3±2.6; p<0.001). Accordingly, multivariate analysis shows an increased mortality risk of 23% for each increase of tertile of social support scale (Hazard ratio=HR=1.23; 95% CI=1.01-1.51; p=0.045). Moreover, when the analysis was performed considering different degrees of comorbidity we found that social support level was predictive of mortality only in subjects with the highest comorbidity (HR=1.39; 95% CI=1.082-1.78; p=0.01). Thus, low social support is predictive of long-term mortality in the elderly. Moreover, the effect of social support on mortality increases in subjects with the highest comorbidity.

Multidisciplinary approach to "accidental" falls in the elderly: a case report.

Falls in the elderly are commonly and often wrongly identified as "accidental". We report a case of an elderly woman admitted to first aid for a trauma due to an accidental fall. Geriatric multidisciplinary evaluation revealed mild cognitive impairment associated with depressive symptoms; both findings made the anamnesis uncertain. Syncope algorithm was applied and "tachy-brady form of sick sinus syndrome" was diagnosed. Differential diagnosis between "accidental" and "apparently accidental" falls in elderly patients is very difficult but a multidisciplinary geriatric evaluation can clarify the correct diagnosis.

Mortality and heart rate in the elderly: role of cognitive impairment.

Mortality related to heart rate (HR) increase in the elderly has not yet been well established. To ascertain the relationships among cognitive impairment (CI), mortality, and HR increase, the authors prospectively studied a random sample of elderly subjects stratified according to presence or absence of CI. Elderly subjects randomly selected in 1991 (n = 1332) were followed up for 12 years. Mortality was established in 98.1% of the subjects. When HR was stratified in quartiles (< 69, 70-75, 76-80, and > 80 bpm), mortality was linearly associated with increased HR in all (from 47.7 to 57.0; r2 = .43, p = .019) and in subjects without (from 41.7 to 51.1%; r2 = .50, p = .043) but not in those with CI (from 57.5 to 66.1; r2 = .20, p = .363). Cox regression analysis, adjusted for several variables, shows that HR doesn't predict mortality in all subjects (RR 0.69; 95% CI = 0.27-1.73) or in those with CI (RR 0.91; 95% CI = 0.81-1.02). In contrast, HR predicts mortality in subjects without CI (RR 1.10; 95% CI = 1.00-1.22). Hence, HR increase is a predictor of mortality in elderly subjects without CI. However, when considering all elderly subjects and those with CI, HR increase seems to have no effect on mortality. Thus, CI should be considered when focusing on HR increase as risk factor for mortality in the elderly.

A randomized, double-blind comparison of lercanidipine 10 and 20 mg in patients with stable effort angina: clinical evaluation of cardiac function by ambulatory ventricular scintigraphic monitoring.

We evaluated the antiischemic action and the effects on left ventricular response to exercise of lercanidipine, a long-acting dihydropyridine calcium antagonist, in 23 patients with stable effort angina in a randomized, double-blind, parallel trial. Left ventricular function was assessed during upright bicycle exercise using an ambulatory radionuclide detector for continuous noninvasive monitoring of cardiac function. Exercise was performed under control conditions before (run-in placebo period) and after 2-week treatment with lercanidipine 10 or 20 mg once daily. During the placebo run-in period and at the study end, patients underwent clinical examination, ECG, exercise tests, ambulatory ventricular scintigraphic monitoring (VEST). Results showed that both drug doses increased time to onset of ST segment depression >/=1 mm and peak ST segment depression, with improvement of total exercise duration. Heart rate, blood pressure, and the rate-pressure product did not significantly change with respect to pretreatment value. The left ventricular ejection fraction, indicating contractility state of myocardium, was unchanged at rest and during exercise after both lercanidipine doses. In conclusion, lercanidipine is safe and effective in reducing ischemia in patients with stable effort angina without any deterioration of cardiac function.