Prevalence and features of delirium in older patients admitted to rehabilitation facilities: a multicenter study

BACKGROUND

Delirium is thought to be common across various settings of care; however, still little research has been conducted in rehabilitation.

AIM

We investigated the prevalence of delirium, its features and motor subtypes in older patients admitted to rehabilitation facilities during the three editions of the "Delirium Day project".

METHODS

We conducted a cross-sectional study in which 1237 older patients (age ≥ 65 years old) admitted to 50 Italian rehabilitation wards during the three editions of the "Delirium Day project" (2015 to 2017) were included. Delirium was evaluated through the 4AT and its motor subtype with the Delirium Motor Subtype Scale.

RESULTS

Delirium was detected in 226 patients (18%), and the most recurrent motor subtype was mixed (37%), followed by hypoactive (26%), hyperactive (21%) and non-motor one (16%). In a multivariate Poisson regression model with robust variance, factors associated with delirium were: disability in basic (PR 1.48, 95%CI: 1.17-1.9, p value 0.001) and instrumental activities of daily living (PR 1.58, 95%CI: 1.08-2.32, p value 0.018), dementia (PR 2.10, 95%CI: 1.62-2.73, p value < 0.0001), typical antipsychotics (PR 1.47, 95%CI: 1.10-1.95, p value 0.008), antidepressants other than selective serotonin reuptake inhibitors (PR 1.3, 95%CI: 1.02-1.66, p value 0.035), and physical restraints (PR 2.37, 95%CI: 1.68-3.36, p value < 0.0001).

CONCLUSION

This multicenter study reports that 2 out 10 patients admitted to rehabilitations had delirium on the index day. Mixed delirium was the most prevalent subtype. Delirium was associated with unmodifiable (dementia, disability) and modifiable (physical restraints, medications) factors. Identification of these factors should prompt specific interventions aimed to prevent or mitigate delirium.

Lifestyle and Life Expectancy Questionnaire: validation and assessment in an Italian sample

BACKGROUND

The objective of this study was to evaluate the relia-bility and validity of the lifestyle (Miller-Smith) and life expectancy (Schneider) questionnaires in the Italian setting in order to make this instrument available for the determination of lifestyle and hope level in the different domains of everyday life.

METHOD

Before testing their psychometric properties, the original versions of the two questionnaires, lifestyle (Miller-Smith) and life expectancy (Schneider), were translated into the Italian language. We tested the instrument's psychometric properties on a sample of 18 patients over 60 years old with Alzheimer's disease in the Sapienza University of Rome teaching hospital, policlinico Umberto 1. Internal consistency was considered to assess the reliability of the results across items within the adopted scale by using Cronbach's α coefficient. Using Kolmogorov-Smirnov's test, the normality distribution was evaluated to guarantee the applicability of a parametric or non-parametric test. The software used to analyze data was SPSS version 26 for Windows.

RESULTS

According to the outcome of our statistical analysis, the lifestyle scale showed high overall internal consistency, and the Cron-bach's α coefficient for the total 20-item scale was 0.80 in the Italian population. On the other hand, using the 12-item questionnaire about life expectancy resulted in a high overall internal consistency of 0.93, according to the Cronbach's alpha test.

CONCLUSIONS

The outcome of our study shows that the Italian versions of the lifestyle (Miller-Smith) and life expectancy (Schneider) questionnaires demonstrated good psychometric properties and good characteristics of factorial validity for future epidemiological studies aimed at evaluating lifestyle and lifestyle expectancy in the Italian population and can as well be used in clinical practice and research.

The association between low skeletal muscle mass and delirium: results from the nationwide multi-centre Italian Delirium Day 2017

Introduction

Delirium and sarcopenia are common, although underdiagnosed, geriatric syndromes. Several pathological mechanisms can link delirium and low skeletal muscle mass, but few studies have investigated their association. We aimed to investigate (1) the association between delirium and low skeletal muscle mass and (2) the possible role of calf circumference mass in finding cases with delirium.

Methods

The analyses were conducted employing the cross-sectional “Delirium Day” initiative, on patient 65 years and older admitted to acute hospital medical wards, emergency departments, rehabilitation wards, nursing homes and hospices in Italy in 2017. Delirium was diagnosed as a 4 + score at the 4-AT scale. Low skeletal muscle mass was operationally defined as calf circumference ≤ 34 cm in males and ≤ 33 cm in females. Logistic regression models were used to investigate the association between low skeletal muscle mass and delirium. The discriminative ability of calf circumference was evaluated using non-parametric ROC analyses.

Results

A sample of 1675 patients was analyzed. In total, 73.6% of participants had low skeletal muscle mass and 24.1% exhibited delirium. Low skeletal muscle mass and delirium showed an independent association (OR: 1.50; 95% CI 1.09–2.08). In the subsample of patients without a diagnosis of dementia, the inclusion of calf circumference in a model based on age and sex significantly improved its discriminative accuracy [area under the curve (AUC) 0.69 vs 0.57, p < 0.001].

Discussion and conclusion

Low muscle mass is independently associated with delirium. In patients without a previous diagnosis of dementia, calf circumference may help to better identify those who develop delirium.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40520-021-01950-8.

Handgrip Strength Predicts Longitudinal Changes in Clock Drawing Test Performance. An Observational Study in a Sample of Older Non-Demented Adults

OBJECTIVE

Impairment of physical performance might identify older people at higher risk of dementia over time. The present study evaluated handgrip strength as independent predictor of cognitive decline.

DESIGN

Observational, prospective. Follow-up duration: 11.2 ± 0.8 months.

SETTING AND PARTICIPANTS

Geriatric outpatients center. 104 consecutive stroke- and dementia-free older adults (44% men, ages 80.2 ± 5.4 years).

METHODS

The Clinical Dementia Rating scale and the Clock Drawing Test (CDT) were administered. Handgrip strength was assessed using a Jamar hand dynamometer. Brain magnetic resonance imaging studies at 1.5 T were performed. White matter damage was expressed as severity of white matter hyperintensities (WMHs). Longitudinal changes in cognitive function were expressed as 1-year decline in CDT performance.

RESULTS

A robust association was observed between baseline handgrip strength and 1-year cognitive decline after multiple adjustment. Of note, the strength of such association was only minimally attenuated after adjusting for deep WMHs extent (β coefficient for handgrip strength = 0.183, SE= 0.038, p= 0.007, R2= 0.58).

CONCLUSIONS

Handgrip strength predicted accelerated 1-year decline in cognitive function, assessed by CDT, in a sample of older adults. Future studies are needed to elucidate the causal mechanisms linking limitations in physical function with dementia risk.

Exercise training and music therapy in elderly with depressive syndrome: a pilot study

OBJECTIVE

Recent studies have thrown doubt on the true effectiveness of anti-depressants in light and moderate depression. The aim of this study is to evaluate the impact of physical training and music therapy on a sample group of subjects affected by light to moderate depression versus subjects treated with pharmacological therapy only.

DESIGN AND SETTING

Randomized controlled study. Patients were randomized into two groups. Subjects in the pharmacotherapy group received a therapy with antidepressant drugs; the exercise/music therapy group was assigned to receive physical exercise training combined with listening to music. The effects of interventions were assessed by differences in changes in mood state between the two groups.

MAIN OUTCOME MEASURES

Medically eligible patients were screened with the Hamilton Anxiety Scale and with the Geriatric Depression Scale. We used plasmatic cytokine dosage as a stress marker.

RESULTS

We recruited 24 subjects (mean age: 75.5 ± 7.4, 11 M/13 F). In the pharmacotherapy group there was a significant improvement in anxiety only (p<0.05) at 6-months. In the exercise/music therapy was a reduction in anxiety and in depression at 3-months and at 6-months (p<0.05). We noted an average reduction of the level of TNF-a from 57.67 (± 39.37) pg/ml to 35.80 (± 26.18) pg/ml.

CONCLUSIONS

Our training may potentially play a role in the treatment of subjects with mild to moderate depression. Further research should be carried out to obtain more evidence on effects of physical training and music therapy in depressed subjects.

[Effect of AChE and BuChE inhibition by rivastigmin in a group of old-old elderly patients with cerebrovascular impairment (SIVD type)]

AIM

Vascular dementia (VaD) is defined as a loss of cognitive function resulting from ischemic, hypoperfusive, or hemorrhagic brain lesions due to cerebrovascular disease or cardiovascular pathology. The main types of VaD are: Small Vessel Disease Dementia (sVAD), Large vessel disease dementia, hypoperfusive-ischemic dementia and hemorragic dementia. The sVAD is divided into two main categories: subcortical ischemic vascular dementia (SIVD) and cortical dementia. Currently, no drugs are approved for the treatment of VaD. This study aimed to determine whether rivastigmine, a second generation cholinesterase inhibitor with selectivity for the CNS, with capacity to inhibit both acetylcholinesterase (AChE) and butyryl-cholinesterase (BuChE), slows the rate of cognitive decline associated with VaD.

METHODS

Study subjects were 27 male and 43 female outpatients aged 80.03±6.53 years, with Mini-Mental State Examination (MMSE) score ranging batween 22 and 12, affected by VaD. They were included in the study if they were undergoing pharmacological treatment with acetylsalicylic acid 100 mg for at least six months. Patients were divided into two groups: one group was treated with ASA 100 mg and rivastigmine patch 9.5 mg (Rivastigmine group), the other just with ASA 100 mg (ASA group). All patients were followed for 6 months, with a first evaluation (T0) and a second examination after six mounths of treatment (T1).

RESULTS

Statistically data proved as the Rivastigmine group showed constant values at MMSE, compared with patients of the ASA group who experienced decline of their cognitive performances. The same result was found in CDR, ADL, GDS and NPI scales. It is remarkable to underline as Rivastigmine-treated patients had a mean improvement in GDS scales, in comparison with patients of the ASA group who showed a worsening of mood.

CONCLUSION

Rivastigmine-therapy improves cognitive performance in elderly with SIVD.

A self-administered questionnaire to screen the risk of dementia: a pilot study and the results of a comparison with the mini-mental state examination (MMSE)

Cognitive impairment is an age-related condition as the rate of cognitive decline rapidly increases with aging. The aim of this study was to screen the risk of cognitive decline in people over 60 years from 16 different Italian cities, by comparing the results of a self-administered questionnaire with the MMSE. We analyzed data from 203 persons aged 60 years and over, who voluntarily accepted to participate during the "Second Prevention Day for AD". A self-administered questionnaire, developed by clinicians of our Department of Aging, was distributed to all participants, in order to easily screen the risk of cognitive impairment. Then, all subjects underwent cognitive assessment by MMSE. We esteemed the risk of cognitive impairment of all participants basing on MMSE scores (no risk, mild and moderate risk) and we compared this assessment with the results obtained by the self-administered questionnaire. The comparison between the risk of cognitive impairment revealed by our questionnaire and the risk esteemed by MMSE resulted in a discrepancy in 43.96% of cases in no risk class. In mild risk group there was a discrepancy of results in 70.53% of subjects. In moderate risk class there was a discrepancy of results in 38.46% of individuals. Our questionnaire resulted to be accurate for the evaluation of patients with moderate risk of cognitive impairment. It showed a lower accuracy for the mild risk class, often overestimating the risk of cognitive decline.

New frontiers of cognitive rehabilitation in geriatric age: the Mozart Effect (ME)

The ME was described for the first time in 1993. Subsequently other studies with similar designs were performed. The present study, therefore, proposes: (i) to verify the existence of the benefits of exposure to music in elderly subjects with mild cognitive impairment (MCI), (ii) to explore whether it is possible to find any lasting improvement after training, conducted for a long period of time, with such musical pieces, in the measurable cognitive performances. The study we conducted showed that the ME is present in geriatric patients with MCI; the influence on spatial-temporal abilities remains constant in time if the stimulation is maintained. The continuation of our study will consist of increasing the number of individuals examined and in having them listen to music during the study of ECG rhythms and during the acquisition of cerebral functional magnetic resonance imaging (fMRI), and, at the same time, testing them by neuropsychometric methods.

Is there a relationship between high C-reactive protein (CRP) levels and dementia?

Inflammation is believed to play a pivotal role in dementia, but its role is still unclear. The aim of our study was to analyze the interplay among markers of inflammation, such as fibrinogen and high CRP levels, and dementia. First, we performed a cross-sectional study comparing markers of inflammation between 99 patients affected by dementia (mean age: 83.0+/-0.6 years) and 99 controls (mean age: 83.9+/-0.7 years). Then, we analyzed the relationship between inflammation and dementia in the same population composed by 34 Alzheimer's disease (AD) patients (mean age: 83.4+/-0.8 years), 64 vascular dementia (VaD) patients (mean age: 82.7+0.8 years) and 99 controls. Patients affected by dementia had higher CRP levels than controls (2.6+/-+/-0.2 vs. 0.7 + 0.1 p < 0.001, respectively). AD patients had higher CRP levels than VaD patients (4.2 + 0.6 vs. 1.7+/-0.2, p < 0.001, respectively). Stepwise multiple logistic regression analysis showed that dementia (odds ratio=OR=4.965, 95% confidence interval=Cl=1.402-13.23, p=0.004), fibrinogen (OR=1.011, Cl=1.007-1.015, p<0.001), and age (OR=1.158, Cl=1.063-1.261, p<0.001) are independently correlated with high levels of CRP. The study suggests that inflammation may have a pathogenetic role in AD.

Smoking and longevity: an incompatible binomial?

In Western countries data from clinical and epidemiological studies have induced the public health offices to promote a great deal of advertising and informative campaigning for smoking reduction. Cigarette smoking has been clearly linked to the most common causes of death in the elderly and contributes to the higher death rate and disability rate associated with many chronic illnesses that are common in this age group. The combination of smoking along with other risk factors like hypertension and diabetes increase high frequency diseases, disability as well as adding to an increase in mortality rate. In order to verify if a healthy lifestyle really favors longevity and how much smoking is incompatible with extreme longevity we investigated the prevalence of smokers and the total smoking exposure of a sample of centenarians in relation with residual survival and health conditions. Our sample consists of 157 centenarians living in Rome, 39 males and 118 females (ratio m/f =1:3),mean age being 101.59 +/- 1.8 years (+/-SD), 83.8% of the centenarians have never smoked,13.5 % are former smokers, and 2.7% are active smokers. The average starting age of smoking is 21.2 years, while the average age of quitting is 65.7 years with an average of 44.7 +/- 17.1 smoking years. The average number of smoked cigarettes per day is quite low,less than 10 cigarettes, so that the total average number of smoked cigarettes is 158,045,well under 280,000 which is considered the cut-off point in many studies of when tumors are noticed. There seemed to be a significant difference (p < 0.001) in gender results in smokers: among male centenarians smokers reached 46%, while female smoker centenarians reached only 8.1%. Statistically significant chronic illnesses were noted among centenarian smokers over the age of 65 (p < 0.02). Moreover, Cox's regression has shown in centenarians a lower survival rate (p < 0.05) in smokers (20.7 +/- 11.2 months) than in non-smokers (27.0 +/- 19.0 months). In conclusion, our study evidences that smoking is for all but some exceptional subjects, incompatible with successful aging and compromises life expectancy even in extreme longevity.

Correlation between cognitive impairment and the Rey auditory-verbal learning test in a population with Alzheimer disease

Patients affected by Alzheimer disease (AD) need an accurate diagnosis, to the extent allowing us to find the best therapy or polytherapy, in order to take under control their cognitive impairment. In our Alzheimer Evaluation Units (from the Italian name abbreviated: UVA), the patients undergo a multidimensional evaluation, which can address us towards a proper diagnosis and of other weakening, or even dementia-related diseases. The patients are also subject to neuropsychometric and neuropsychological evaluations, allowing a more focused analysis on cognitive impairments. Among the tests, we use the Rey auditory-verbal learning test (RAVLT), evaluating the patient's verbal memory. A list of 15 words is read to each patient. N the first part of the test, the clinician repeats 5 times such a list. the patient is hen asked, at the end of every repetition, to tell all words he/she remembers. This part is useful to evaluate the immediate recall (IR) ability. The score, i.e., the total number of recalled words, ranges from 0 to 75. After 15 minutes, the delayed recall (DR) ability is evaluated: the patient is newly asked to repeat as many words as he can recall from the list. The score for this part ranges from 0 to 15 minutes. The score is corrected of rage and education, with a cut-off of 28.5 for IR and 4.7 for DR. We made a survey with the purpose of deciding if there was a correlation between cognitive impairment and verbal memory lack, whose deficiency appears earlier in AD. To this aim, we selected several patients with AD, diagnosed during the period between September 2002 and February 2003. We only considered those patients whose AD was not associated with other weakening diseases, and whose clinical dementia rating scale (CDR) score was between 0.5-2.0. A sample of 35 individuals (11 men and 24 women) could be obtained. A meaningful correlation was observed between CDR and IR (r = -0.725, p < 0.01), as well as between CDR and DR (r = -0.470; p < 0.05). Such a result confirms the importance of evaluating immediate and long-term memories, for the early diagnosis of AD, because it is the only symptom of clinically not yet diagnosed dementia, as proven also by other studies.

THE MANAGEMENT OF PSYCHOGERIATRIC PATIENT

The exponential growth in the prevalence of cognitive impairment of old patients leads the physicians to deal with a larger incidence of behavioral disorders (such as excitement,aggressiveness), and psychotic symptoms (such as delirium and visual hallucinations). The presence of psychotic troubles in dementia causes a remarkable distress to caregivers and involves higher difficulties in the patient management. The estimates of such troubles range between 15 and 75 %. Geriatric assessment and the management of behavioral troubles require a prompt evaluation of all their possible causes. As a matter of fact, their appearance often reveals a physical disturbance (pain, fever, etc.), or adverse environmental conditions, or it could also be a consequence of a multiple drug therapy. For this reason,the use of antipsychotics should always be preceded by an accurate clinical diagnosis.Anxiolytic, anti-depressive, anti-convulsive and anti-psychotic drugs are among the therapeutic strategies for the management of the psychogeriatric patient. Atypical antipsychotics seem to be able to decrease the psychotic symptoms, with low levels of therapeutic failure. They also reduce extrapyramidal effects and the growth of prolactine hormone, which is quite useful when dealing with very old patients. Risperidone and olanzapine are two atypical anti-psychotics, which already proved to be adequate and well tolerated during the treatment of schizophrenia and of acute maniacal disorders. Our experience, with a population of patients followed by our Alzheimer Evaluation Unit (AEU), confirms that a low dose of olanzapine (5mg/day) and risperidone (0.5-1.0 mg/day) are effective in lowering behavioral disturbances, and psychotic symptoms due to dementia. Even in the long run,low doses of these drugs are still well tolerated. Higher levels of risperidone (> 1 mg/die)often caused extra-pyramidal symptoms such as rigidity and dyskinesia, whereas higher levels of olanzapine (> 5 mg/day) lead to an exceeding sedation. The management of behavioral disturbances is one of the most important goals in the global treatment of patients affected by dementia, to the extent of improving the quality of life. Atypical antipsychotics are preferable compared to old-generation drugs, therefore, they are the key therapeutic strategy we cannot renounce.

Long-term users of psychotropic drugs: embodying masculinized stress and feminized nerves

This article examines long-term users of psychotropic drugs (43 men and 57 women) and their views on women's and men's reasons for using these drugs. The data came from written statements (N= 56) given on open-ended questions from a survey of users and from taped interviews with 10 respondents. Men's accounts expressed a notion of men as experiencing external pressures which created "masculinized stress." On the one hand, this stress could be handled with alcohol, while, on the other hand, the use of psychotropic drugs indicated a loss of men's assumed self-regulatory power and autonomy. Women related the reasons for their psychotropic drug use to their experience of emotional labor. Nevertheless, they did not tend to identify the psychological consequences of their experience as related to work. Rather, they labelled these as health consequences--women being more "emotional" than men and suffering from "nerves." These lay accounts reflect the representations of gender-specific psychological distinctions and the effort to construct gender-specific etiologies.

Prenatal screening and genetics

Although the term 'genetic screening' has been used for decades, this paper discusses how, in its most precise meaning, genetic screening has not yet been widely introduced. 'Prenatal screening' is often confused with 'genetic screening'. As we show, these terms have different meanings, and we examine definitions of the relevant concepts in order to illustrate this point. The concepts are i) prenatal, ii) genetic screening, iii) screening, scanning and testing, iv) maternal and foetal tests, v) test techniques and vi) genetic conditions. So far, prenatal screening has little connection with precisely defined genetics. There are benefits but also disadvantages in overstating current links between them in the term genetic screening. Policy making and professional and public understandings about screening could be clarified if the distinct meanings of prenatal screening and genetic screening were more precisely observed.

[Rehabilitation in Alzheimer's dementia]

Alzheimer's disease is a neurodegenerative disease that causes a progressive decline of cognitive and behavioural functions. The simultaneous presence of these disorders requires a treatment not only for cognitive decline, but also for behavioural symptoms, depression and caregiver's stress. Research has made many efforts to develop a wide range of treatments, different from current pharmacological therapy, which is not resolutive, owing to the absence of an exact etiopathogenetic mechanism. Since new drugs have not been shown to be really effective in slowing cognitive impairment, various forms of rehabilitative interventions have been proposed in order to treat Alzheimer's disease. Their efficacy in the improvement of cognitive functions is still not completely clear. Surely, interesting results have been obtained from studies about Reality Orientation Therapy, Occupational Therapy and Memory Training. Music therapy might provide a new form of rehabilitative intervention, especially acting on the reducing of behavioural symptoms. These alternative forms of non pharmacological treatment may have a positive effect on caregiver. The heavy emotional burden of seeing a loved one becoming confused and isolated and of having to accept new responsibilities, may be reduced by rehabilitative supports, complementary to the pharmacological therapy. Caregiver stress could be reduced in two ways: by promoting the hope that something is being done for the patient and providing free time for himself.

Reproductive genetics, gender and the body: 'please doctor, may I have a normal baby?'

This paper's purpose is to highlight key sociological issues, that come to light when 'the body' becomes a theoretical site in reproductive genetics. By positioning the body as a central feature in this analysis, the paper: (1) describes how a mechanistic view of the body continues to be privileged in this discourse and the effects of this view; (2) examines how reproductive limits are practised on the gendered body through a feminised regime of reproductive asceticism and the discourse on shame; and (3) explores the social effects and limitations of reproductive genetics in relation to disability as a cultural representation of impaired bodies. The central assumption concerning reproductive genetics are that it appears within surveillance medicine as a part of a disciplinary process in society's creation of a genetic moral order, that it is mobilised by experts for the management of reproductive bodies and that it constructs a limited view of the body. Thus, the way reproductive genetics operatives tends to hide the fact that what may appear as 'defective genes' is a result of a body's interaction not only with the environment but also gendered social practices valorised by difference as well as rigid definitions of health and illness. The research is from a 1995-96 European study of experts interviewed in four countries.

Mental distress--gender aspects of symptoms and coping

The article examines men's and women's views on their reasons for mental distress and on their coping styles, respectively. The data were taken from written statements given on two open-ended questions from a survey questionnaire returned by 43 men and 57 women who were self-reported, long-term users of these drugs, and from taped interviews with 10 respondents. Men's accounts (n = 25) expressed a layered theory of mental health: alcohol was a remedy to alleviate temporary strain caused by external pressure, while the use of psychotropic drugs indicated a loss of a men's assumed self-regulatory powers and autonomy. Women's accounts (n = 31) were stories of emotional pain related to their caring work in the private sphere, and psychotropics restored their capacity to carry out emotional labor.

Mortality rates and antihypertensive therapy in extreme old age

The impact of hypertension on survival in extremely old age has shown different features in different studies, with equal or lower mortality rates in hypertensive patients and lower reduction of risk in treated patients. In a population (n=414) of old community dwellers (mean age 88.4 years) the prevalence of hypertension was 52.2%. Hypertensive patients presented a lower mortality rate (14.2 per 100 person-years) as compared to the general population (15.4) and to non-hypertensives (16.6). Hypertensives were divided into four groups according to treatment. Best survival was shown by patients under treatment with antihypertensives alone (9.8) or in association with diuretics (9.9), and worst survival by patients under a diuretic-based treatment (25.1). These data were confirmed by multivariate analysis. The better survival of hypertensive very old people could be related to the use of a proper pharmacotherapy.

Psychotropic drugs: long-term use, dependency and the gender factor

The study examines the factors contributing to the initiation, continuation and termination of use among female and male long-term users of minor and major tranquilizers. The findings show the importance of the lay-referral system as a channel of introduction to psychotropic drug use, especially for men. The issue of dependency is explored both in terms of the users' own interpretation of its nature and their reports on the professional responses to their long-term use. The findings indicate that gender and drug use are intricately linked in both the non-professional and professional treatment of anxiety and insomnia.