Multidimensional geriatric assessment in treatment decision in elderly cancer patients: 6-year experience in an outpatient geriatric oncology service.

This prospective cohort study of consecutive elderly cancer patients was undertaken to evaluate the role of the multidimensional geriatric assessment (MGA) as an aid in treatment decision-making. A total of 571 cancer patients (aged > or =70) were enrolled during 6-year (1999-2005). All underwent MGA as part of the first evaluation. In multivariate analysis, the probability of receiving active, instead of palliative, treatment was negatively associated with increasing age (odds ratio=0.69 every 5 years, p=0.005), living alone (OR=0.54, p=0.031), dependence in activities of daily living (ADL score >0, OR=0.41, p=0.003) and a low body-mass index (BMI) (OR=0.51, p=0.061); while a positive association emerged for instrumental activities of daily living (IADL) score (OR=1.12 per point, p=0.019). Our data suggest that MGA, in addition to age, is a useful tool in clinical practice for deciding cancer treatment in elderly patients, with a major independent role played by living alone, ADL, IADL and BMI.

Depressive symptoms and quality of life in elderly patients with exacerbation of chronic obstructive pulmonary disease or cardiac heart failure: preliminary data of a randomized controlled trial.

Aim of the study was to evaluate mortality and functional, cognitive, affective status in elderly patients (>or=75 years) with exacerbation of chronic obstructive pulmonary disease (COPD) or acute congestive heart failure (CHF) admitted to the emergency department (ED) of S. Giovanni Battista Hospital of Torino and randomly assigned to the geriatric home hospitalization service (GHHS) or to a general medical ward (GMW). All patients were evaluated on admission, on discharge and at 6 months, using a standardized study protocol. We excluded patients with unstable medical conditions. The total sample included 73 patients: 35 with COPD exacerbation (19 GHHS, 16 GMW) and 38 with CHF (19 GHHS, 19 GMW). Mean age was 81.7+/-8.0 years. At baseline, no significant differences in demographic, social and clinical conditions were found between the two groups of patients. 56.7% of COPD patients had a severe exacerbation, according to Anthonisen criteria; 65% of CHF patients were NYHA-III and 35% NYHA-IV (according to the criteria of the New York Heart Association) (FE<35% in 40% of patients). On admission all patients were partially dependent in ADLs and IADLs, with a moderate impairment of depression score and a fairly good quality of life. On discharge depression score and quality of life were significantly better only in GHHS patients. Mortality was similar in the two setting of care. Patients managed at home had a significantly longer length of treatment. At 6-month follow-up we did not observe a difference in mortality, but we observed a higher readmission rate in patients previously treated in hospital. In conclusion, our study indicates that home-treated patients with COPD or CHF have better depressive scores and quality of life and a lower rate of hospital readmission after six months.

Clinical outcomes in elderly demented patients and caregiver's stress: a 2-year follow-up study.

We have conducted a study on 82 elderly patients with advanced dementia admitted to the Geriatric Department of S. Giovanni Battista Hospital of Torino in order to evaluate mortality, functional and cognitive impairment and caregiver's stress at 2-year follow-up. Patients were examined using a standardized protocol which included demographic characteristics, comorbidity, duration and type of dementia, severity of disease (clinical dementia rating scale: CDR), behavioral disturbances (neuro-psychiatric inventory: NPI), functional status (activities of daily living: ADL, and instrumental activities of daily living: IADL), cognitive status (short portable mental status questionnaire: SPMSQ). Characteristics of primary caregivers were evaluated and their level of stress was assessed by the relatives' stress scale (RSS). After two years, mortality in the total sample was 61%; the mean age of survivors was 81.3+/-5.3 years; 88% of the sample was still living at home with a relative (76%) or with paid personnel (24%). A statistically significant worsening of the cognitive status was detected (baseline SPMSQ=7.5+/-1.7; follow-up SPMSQ=8.4+/-1.8; p<0.05). Functional status did not change significantly, since it resulted already seriously compromised at the beginning of the study. Most caregivers (80%) were the same as two years before and their stress level was very high (baseline RSS=36.6+/-13.9; follow-up RSS=33.2+/-14). In conclusion, most of the patients included in the follow-up were still living at home, despite the high caregiver's burden and the increasing severity of the disease. Therefore, there is a strong need to further improve health services for the patients with advanced dementia living in their homes.

Is videopupillography useful in the diagnosis of Alzheimer's disease?

Patients with Alzheimer's disease (AD) reportedly exhibit greater pupillary dilation than healthy subjects in response to tropicamide. By means of videopupillography, we have found that the average basal pupillary diameter was greater in AD patients than in normal controls and that there is an inverse relationship between the average pupillary diameter and the maximal dilation obtained following tropicamide application in both groups. Pupillary response to tropicamide and videopupillography do not distinguish between Alzheimer's patients and controls.

A case-control study on lymphocytic subsets in elderly bearing a gastroenteric cancer.

The aim of this work is to evaluate the differences in lymphocytic sub-classes between elderly patients with gastroenteric cancer and elderly patients with a non neoplastic disease. A group of 88 patients over 60, consecutively admitted to the III Division General Surgery for gastro-enteric cancer has been collected for the study, the control group consisted of 74 patients also over 60, consecutively admitted over the same period for benign abdominal diseases. In all patients the following data were measured: body mass index (BMI), white blood cells (WBC), total lymphocytes, total T lymphocytes (CD3+), helper T lymphocytes (CD4+), suppressor T lymphocytes (CD8+), CD4+/CD8+ ratio, B lymphocytes, CD5+ B lymphocytes, activated T lymphocytes (CD3+ HLA-DR+), CD4+ "naive" lymphocytes (CD4+ CD45 RA+), CD4+ "memory" lymphocytes (CD4+ CD45 RO+), NK lymphocytes (CD16+ 56+), red blood cells (RBC), total serum cholesterol, albumin, total serum proteins. The main lymphocytic subsets were on an average lower in the cancerous elderly group with respect to the non cancerous. As the tumour progressively increases in size (T), total lymphocytes significantly decrease, while CD4+ progressively decreases with nodal involvement (N). In the cancerous elderly, we found a lower immune response. The immune system appears to be less efficient also in association with tumor growth, especially when T and N get worse. The response of effector cells to the tumour seems not specific.

[Neuropsychologic symptoms of primary hyperparathyroidism in the elderly. Report of a clinical case]. / Sintomatologia neuropsichica da iperparatiroidismo primitivo nell'anziano. Descrizione di un caso clinico.

Primary hyperparathyroidism is a not uncommon disease in the elderly. A prevalence of 3% for women and 1% for men is reported in subjects aged 65 years and over. Routine serum calcium determination and parathyroid hormone radioimmuno-assay allow to make an early diagnosis in still asymptomatic subjects. In the elderly the clinical features of the disease are often aspecific presenting with psychiatric and/or neuromuscular and/or cardiovascular disorders. This report refers to a 75 year-old woman admitted to our Department with a suspicion of senile dementia. She was affected by loss of memory, hallucinations, nausea, loss of appetite, mild polydipsia and polyuria. The patient was dependent in one activity of daily living (Index of Independence in Activities of Daily Living, ADL) and partially dependent in instrumental activities of daily living (Instrumental Activities of Daily Living Scale, IADL). The Short Portable Mental Status Questionnaire (SPMSQ) and the Geriatric Depression Scale (GDS) showed mild mental impairment and mild depression. Routine biochemical screening revealed a significant hypercalcemia. Parathormon assay and parathyroid scintigram were performed to confirm the diagnosis of primary hyperparathyroidism. After treatment of dehydratation and hypercalcemia, parathyroidectomy was performed: a single parathyroid adenoma was found and removed. On discharge the patient was lucid and able to carry out all ADLs and IADLs.

Hypernatremic dehydration in the elderly on admission to hospital.

Dehydration is the most common cause of fluid and electrolyte disturbances in the elderly. This condition is related to the lack of increase in water intake in the presence of an increased fluid loss. The aim of this study was to evaluate the prevalence of hypernatremic dehydration in elderly patients admitted to the hospital. We retrospectively studied 2,894 subjects admitted to the acute ward of the Geriatric Section of the Department of Medical and Surgical Disciplines of the University of Torino from January 1990 to July 1995. Among them 84 (2.9%) patients, mean age 77.3 +/- 9.8 years, had serum sodium levels and blood urea nitrogen greater than 145 mEq/L and 25 mg/dL respectively with serum creatinine below 3 mg/dL. The prevalence of hypernatremic dehydration increases with age. Only 1.6% of the subjects under 65 years old are affected by this condition, against 5.3% of those over 85 years. The mortality rate observed during hospitalization is 29.8%. Mortality is positively related to serum sodium levels. We found mortality rates of 33.3% and 71.4% respectively in subjects with serum sodium levels from 151 to 153 mEq/L and in those with values over 154 mEq/L. Both serum sodium levels and age are independent risk factors for mortality (O.R. 1.31 and 1.07 respectively).

Health and functional status in elderly patients living in nursing homes.

Socio-economic background, functional status, multiple pathology and medical conditions requiring care have been evaluated in 506 elderly subjects living in nursing homes in Turin (Italy). In the sample 78.8% are women, mean age 84.2 years, only 21.2% are men, mean age 76.3 years. Particularly in the oldest age classes women are more represented than men. Most subjects (94.3%) require help in at least one Activity of Daily Living (ADL). Part of the sample (21.2%) comes from home, 13.2% from acute wards, 9.1% from long term care wards, 6.3% from mental hospitals, 26.3% from residential homes. Education level is rather low. Before retirement, many men were workmen (38.3%), while many women were housewives (46.6%). Multiple pathology is very common: 23.7% of patients suffer from 4 pathologies, more than 5 diseases are present in 18.8%, while only 4.7% of subjects have less than two pathologies. Half of the sample (52.6%) is affected by dementia, 37.6% by cardiovascular diseases, 29.1% by chronic obstructive lung disease and 25.5% by stroke. Bone fractures are present in 22.1% of the subjects. Severe impairments in strength and/or motility in at least two limbs affect 43.7% of patients, double incontinence 49.2%, severe disturbances in speech and communication 35.4%. The prevalence of care needs is higher in women compared with men. More females than males need aid in walking, help in eating, diapers, pressure sores prevention and bedposts.

Functional vascular disorders: treatment with pentoxifylline.

A group of 11 female patients (mean age 33.7 +/- 8 years) with a clearly proven primary Raynaud's syndrome of up to five years' duration were subjected to a two-month oral treatment with 3 X 400 mg pentoxifylline per day. The following parameters were studied without and with exposure to cold conditions: hemodynamics (finger photoplethysmography), red cell deformability (filtration test), various clotting variables (prothrombin activity, antithrombin III, plasma fibrinogen, partial thromboplastin time, thrombin time, thrombelastogram), and clinical symptomatology. After treatment 7 of the 11 patients showed a distinct improvement of peripheral blood flow and of symptoms (decrease or removal of asphyxia attacks, pain, color change) under basal conditions, as well as after exposure to cold. Red cell filtration was significantly (p less than 0.05) improved, increasing by 35% under normal conditions and by 30% after exposure to cold. Positive changes were also found in respect to antithrombin III (increase) and plasma fibrinogen (decrease). The thrombelastogram was unchanged. Clinical and instrumental improvements were probably ascribable to better microcirculatory flow due to increased red cell deformability, reduced viscosity, and decreased fibrinogen, all capable of influencing in various degrees the blood flow at the microcirculatory level.

Determination of selected trace elements in patients affected by dementia.

The relationship between dementia and trace elements is widely debated. Neurotoxicity of aluminium is well recognized. The purpose of the study was to evaluate serum levels of a few trace elements and a few serum proteins in demented subjects. The study was carried out on 452 women, age range 73-88 years. Thirty one of them were affected by dementia of Alzheimer type in early or middle stages. The diagnosis had been performed by history, physical and instrumental examinations, as well as by psychometric tests. The following parameters were determined: iron, zinc, copper, serum albumin, transferrin, ceruloplasmin. Iron, copper and zinc are somewhat lower in demented subjects than in controls, but the differences are statistically not significant. The slightly diminished levels of serum albumin and transferrin in the study group may be related to a mild malnutrition. The reduction of the proteins binding trace elements, particularly of transferrin, could cause a higher bioavailability of neurotoxic trace elements such as aluminium.

Risk profile in women with stroke: role of plasma fibrinogen.

In 96 women with ischemic stroke, (mean age 77.9 +/- 7.4, S.D., years, body mass index, BMI = 23.7 +/- 3.91, we assessed the presence of risk factors for atherosclerosis, particularly of hyperfibrinogenemia. A control group of 96 women without relevant diseases, namely neoplasms, cardiovascular and inflammatory diseases, well matched for age and BMI was also studied. Subjects with stroke show higher values of systolic and diastolic blood pressure, total serum cholesterol, fibrinogen, hematocrit and more frequent habit of cigarette smoking. Levels of HDL-cholesterol, triglyceridemia and glycemia do not differ between the 2 groups. In stroke group fibrinogen is positively correlated with systolic and diastolic blood pressure and triglyceridemia. These findings confirm the presence of a risk profile for stroke, in which hypertension plays the most relevant role. The weight of fibrinogen in pathogenesis of stroke is likely to be related to the presence of other risk factors.

Symptoms as predictors of functioning in the community-dwelling elderly.

This survey was carried out to explore the relationship between symptoms and functional status in the elderly living at home. The setting is an urban area of Turin (Northern Italy). A cross-sectional screening for 20 symptoms was completed in 747 subjects, aged 75 and older. Dependence in basic Activities of Daily Living (ADL) and in Instrumental Activities of Daily Living (IADL), Short Portable Mental Status Questionnaire and Cumulative Illness Rating Scale were also ascertained. A discriminant analysis was performed to determine the potential value of symptoms in predicting functional impairment. The mean number of symptoms was 6.0 per subject (+/-S.D. 3.3) and dependence in ADLs was 8.2%. Amongst a 20-symptom list, six symptoms (fatigue, memory loss, indigestion, nutrition, hearing and speaking problems), either alone or in association, showed sufficient discriminatory power to identify dependence in ADLs (sensitivity=72%), mental impairment (72%), psychological distress (80%), but not dependence in IADLs (48%). Symptoms are common in the free-living elders, but their functional status is good. A short (6 items) formal screening for symptoms may be a simple way to predict functioning and to rapidly manage problems.

Hemorheologic and coagulative pattern in hypercholesterolemic subjects treated with lipid-lowering drugs.

The effects on the coagulative and rheologic pattern of two lipid-lowering drugs, bezafibrate and simvastatin, were studied in 36 hypercholesterolemic subjects. Patients were randomly divided into two groups (18 subjects each) and received bezafibrate R 400 mg/day or simvatatin 10-40 mg/day over a twelve week period. Besides a decrease in plasma fibrinogen and fibrinopeptide A (p less than 0.001 both), bezafibrate induced a reduction of factor VIIc and VIIIc activity (p less than 0.001 both), while antithrombin 3 activity was increased (p less than 0.001) and the hemorheologic pattern was greatly improved (p less than 0.001). Simvastatin caused a slight decrease in factor VIIIc activity and a moderate reduction of beta-thromboglobulin. The efficacy of bezafibrate in reducing the activation of the coagulative cascade and improving the hemorheologic pattern has been confirmed; the peculiar triglycerides- and fibrinogen-lowering effect of the drug, not observed with simvastatin, could be responsible for these modifications.

Nutritional patterns in elderly patients with dementia of Alzheimer type.

Body weight and some nutritional serum parameters (albumin, urea nitrogen, creatinine, glycemia, hemoglobin, total cholesterol, triglycerides, potassium) were analyzed in 44 subjects aged over 60 in order to evaluate weight loss and its possible link with the progression of dementia. Patients were consecutively admitted to our Day Hospital with the complaint of psychogeriatric symptoms. They all were living at home, no one presented risk factors for malnutrition and their cognitive impairment did not exceed the 4th degree of GDS (Global Deterioration Scale). Subjects were divided into two groups on the basis of diagnosis at discharge: (i) Possible or probable dementia of Alzheimer type (30 subjects, mean age 72.1 +/- 5.9 years), (ii) Age-associated memory impairment (14 subjects, mean age 73.6 +/- 6.2 years). One year later, a second control of body weight and nutritional parameters was performed. Differences between these latter measures versus the initial values were not significant when analyzed in the total group of demented patients or in the subgroups with different degree of cognitive impairment and physical activity. A possible hypothesis to explain the absence of differences among groups is that the caregivers were very carefully looking after all the patients examined.

Hemorheolocical and photoplethysmographical modifications with aging.

The association of hemorheological patterns with the common risk factors for atherosclerosis is widely known. There are only few data about hemorheological modifications with aging. The objective of our study was to evaluate the relationships of blood and plasma viscosity, the whole blood and red cell filterability, and the amplitude of photoplethysmographical wave to aging and to some risk factors for atherosclerosis. The study involved 278 healthy women, mean age 55.3 +/- 11.9 (SD) years. Blood viscosity was positively correlated to body mass index (BMI), total cholesterol/HDL ratio, triglyceridemia, glycemia and hematocrit. Plasma viscosity was positively correlated to age, systolic blood pressure, glycemia, and fibrinogen contents. Whole blood filterability was negatively correlated to diastolic blood pressure, triglyceridemia, glycemia, hematocrit, and fibrinogen contents. Red cell filterability was negatively correlated to age, hematocrit, and fibrinogen. The amplitude of photoplethysmographical wave is inversely correlated to age and systolic blood pressure. Our findings show an increase of plasma viscosity, a decrease of red cell filterability and of the amplitude of photoplethysmographical wave with advancing age. These modifications may contribute to the microcirculatory troubles often evident in aging individuals.

Hemodynamic, hemorheologic, and hemocoagulative changes after treatment with picotamide in patients affected by peripheral arterial disease (PAD) of the lower limbs.

Effects of picotamide on platelet activity and on some hemorheologic, coagulative, and hemodynamic parameters were investigated in a randomized, double-blind, placebo-controlled study for eighteen months. Twenty patients, average age 61.5 +/- 9.6 (SD) years, with peripheral arterial disease (PAD) at functional stage 2 of the Fontaine classification and with intermittent claudication for at least six months were studied. Ten patients received tablets of picotamide, 300 mg three times a day, and 10 subjects received three identical placebo tablets each day. Similar atherosclerotic disease risk factors were present in both groups. Picotamide induced a significant decrease of plasma viscosity, fibrinogen, and beta-thromboglobulin and an increase of amplitude of the photoplethysmographic wave.

[Determination of immunoglobulins in the aged. Normal range and changes in pathological conditions]. / Il dosaggio delle immunoglobuline nell'anziano. Ambito di normalità e variazioni in situazioni patologiche.

Serum IgA, IgG and IgM values in 238 normal aged subjects were compared with those in 100 normal adults. Both male and female aged subjects displayed a significant rise in IgA and a significant fall in IgM, whereas IgG values were not markedly different. It was found that IgA increased and IgM decrease by an average of 12 mg % and 10 mg % (17 mg % in the aged) per decade respectively. Values were also determines in 597 aged hospital patients and related to the disease for which they were admitted. Increases in all three Igs were noted in sclerotic cardiopathy, chronic cerebrovascular insufficiency, acute broncopneumopathy (IgA increase only in chronic forms), and gastroduodenal ulcer. Diverticulosis of the colon and acute pancreatitis, however, were accompanied by elevated IgA values only. Increases were particularly marked in chronic liver disease, less so in diseases of the gallbladder. Neoplasia was usually accompanied by higher Ig levels.

[ADP-induced platelet aggregation in vascular diseases of the elderly]. / Aggregabilità piastrinica da ADP nelle vasculopatie dell'anziano.

A study of 60 over-65's, of whom 30 were suffering from coronary disease 15 had previous but now stable cerebrovascular insufficiency and 15 were suffering from circulation insufficiency in the lower extremities, showed that ADP-induced platelet aggregability was significantly increased by comparison with a group of 15 subjects of similar age rigidly selected as "normal". The aggregation rate was more enhanced than other parameters. In patients with coronary insufficiency and in those with cerebral vasculopathy, other aggregability parameters were significantly changed (minimum aggregating concentration). It is concluded that platelet aggregation, which is often increased in physiological ageing, is altered to an even greater extent in the vasculopathic elderly.

[Strain gauge plethysmography of venous circulation in aged patients with deep vein thrombosis and post-phlebitis syndrome]. / Studio del circolo venoso mediante pletismografia "strain gauge" in soggetti anziani con trombosi venosa profonda e sindrome post-flebitica.

Deep-seated venous thrombosis (DVT) is more common in subjects over 40 and is most frequently found in subjects between 60 and 70 years of age. It is thought that the complaint is brought about by paraphysiological factors connected with aging or conditions frequently encountered in the elderly which are interconnected to varying extents. The flow parameters of 30 female subjects with diagnosed DVT, of which 18 were over 60, and 24 female subjects with a phlebographic diagnosis of Post-phlebocytic syndrome (PPS), of which 14 were over 60, were evaluated using the plethysmographic strain gauge technique. Women over 60 with DVT have longer maximum emptying times and higher venous pressures. For this group, maximum emptying time is slightly lower (although not by a statistically significant amount) than for the younger group. Subjects of advanced age with DVT display significantly higher levels of venous obstruction and patients with PPS display higher levels of venous ectasia. These effects are probably caused by venous circulation miopragia due to aging.

[Relations between markers and immunological status in surgical patients. Tumor markers and immunity in surgery]. / Rapporto fra markers e stato immunologico nel paziente chirurgico. Markers tumorali ed immunità in chirurgia.

The correlation between the immunological status of surgical patients and cancer is examined. 52 patients with gastric and colonic cancer were studied. On the basis of the immunological results of skin tests these were subdivided into non-reactive and reactive. The two groups were statistically compared in relation to cancer stage and blood concentrations of 4 markers: CEA, Ca 19-9, Ca-50, T.A.T.I. The first data show that anergic patients are older to a statistically significant degree; the second that there are no significant differences between the two groups as regards cancer stage. The third data show a difference between the two groups in relation to two of the four markers; anergic patients have a statistically significant higher blood concentration of CEA and T.A.T.I. This is rather interesting, since the literature offers no specific studies on the correlation between the patient's immunological status and tumour marker concentration. Therefore, in clinical practice, the high concentrations of these markers, could reveal, as well as the presence of cancer an endangered immunologic status.