Aging and Adherence to the Mediterranean Diet: Relationship with Cardiometabolic Disorders and Polypharmacy

OBJECTIVES

To investigate the association between adherence to the Mediterranean Diet (Med-Diet), cardiometabolic disorders and polypharmacy.

DESIGN

Cross-sectional study.

SETTING

Geriatrics outpatient clinic, Policlinico Umberto I, Sapienza University of Rome.

PARTICIPANTS

508 patients (219 male, 289 female) aged 50 to 89 who were evaluated for cardiovascular and metabolic disorders.

METHODS AND MEASUREMENTS

Patients underwent a comprehensive medical assessment including medical history and the use of medications. Adherence to Med-Diet was assessed using the validated Med-Diet 14-item questionnaire; for the analysis, patients were divided in high (≥8) and medium-low (<8) adherence. Polypharmacy was defined as taking ≥5 medications.

RESULTS

476 patients completed the study. Mean age was 70.4 years; 58% female. Median Med-Diet score was 8 (interquartile range, 6-9). Patients with medium-low adherence had higher body mass index (p=0.029) and higher prevalence of arterial hypertension (p<0.001), previous coronary (p=0.002) and cerebrovascular events (p=0.011), diabetes, (p<0.001) and dyslipidemia (p=0.001) compared to those at high adherence. Med-Diet score decreased with the number of cardiometabolic disorders (p<0.001). The prevalence of polypharmacy was 39%. Consumption of olive oil (p=0.005), vegetables, (p<0.001), wine (p=0.017), legumes (p=0.028), fish (p=0.046) and nuts (p=0.045) were all inversely associated with the overall number of medications. In a multivariable regression model, medium-low adherence to Med-Diet was independently associated to polypharmacy (O.R.:1.859; 95% CI 1.142 to 3.025; p=0.013), after adjusting for possible confounding factors.

CONCLUSION

Med-Diet was inversely associated with cardiometabolic disorders and with polypharmacy, suggesting that improved Med-Diet adherence might potentially delay the onset of age-related health deterioration and reduce the need of multiple medications.

Fall prevention in the young old using an exoskeleton human body posturizer: a randomized controlled trial

BACKGROUND

Fall risk in elderly has been related with physical decline, low quality of life and reduced survival.

AIM

To evaluate the impact of exoskeleton human body posturizer (HBP) on the fall risk in the elderly.

METHODS

150 subjects (mean age 64.85; 79 M/71 F) with mild fall risk were randomized into two groups: 75 for group treated with human body posturizer (HBP group) and 75 for physical training without HBP group (exercise group). The effects of interventions were assessed by differences in tests related to balance and falls. Medically eligible patients were screened with Tinetti balance and Gait evaluation scale, short physical performance battery and numeric pain rating scale to determine fall risk in elderly people.

RESULTS

In the HBP group there was a significant improvement in short physical performance battery, Tinetti scale and Pain Numeric rating scale with a significant reduction in fall risk (p < 0.05). In the exercise group we observed only minimal variations in the test scores.

DISCUSSION

The results at the sixth and twelfth months show a twofold positive effect in the HBP group reducing fall risk and improving quality of life by reducing pain.

CONCLUSION

The use of exoskeleton human body posturizer seems to be a new significant device for prevention of fall in elderly patients. Further research should be carried out to obtain more evidence on effects of robotic technology for fall prevention in the elderly.

The treatment with ursodeoxycholic acid in elderly patients affected by NAFLD and metabolic syndrome: a case-control study

AIMS

Evaluating the prevalence and the degree of steatosis in geriatric patients (65 to 85 years of age) with Metabolic Syndrome (defined by ATP III criteria); searching for metabolic factors which are predictive for the degree of steatosis; evaluating the efficacy of Ursodeoxycholic Acid (UDCA) for 6 months in the treatment of patients with NAFLD or NASH.

MATERIALS AND METHODS

We studied 87 geriatric patients with Metabolic Syndrome. Steatosis was diagnosed and graded by laboratory assessment and ultrasonography, method based on the determination of liver/kidney ratio through grey-scale intensity, which was calculated as an index of the severity of the steatosis: it could oscilates from 0 (none) to 3 (severe). We randomized the geriatric patients into two groups: Ursodeoxycholic Acid (UDCA)-treated group (n=43 pz) and diet-treated group (1200 Kcal/die for female, 1500 Kcal/die for male) (n=44 pz), for a period of 6 months. BMI, principal symptoms, liver function, blood lipids, ultrasonography liver were evaluated respectively before and after treatment.

RESULTS

The prevalence of steatosis was 100% (26 mild steatosis cases, 38 moderate cases and 23 severe cases) in our patients with Metabolic Syndrome. Of the 43 subjects assigned to receive 300-450 mg/d of UDCA and diet, the hepatic steatosis index decreased on the average, of the 75%. Serum AST, ALT and γ-GT decreased significantly at 3 months already (p<0.001).

CONCLUSIONS

UDCA improves liver enzymes and ultrasonography immaging in geriatric patients with NAFLD or NASH. Unexpectedly, UDCA has resulted in beneficial effects on glycemic control and insulin sensitivity.

Hypovitaminosis D: which oral supplement therapy?

OBJECTIVES

the possible therapeutic role of vitamin D in different kind of diseases explains the growing interest in this vitamin due to its pleiotropic effects. This short report shows preliminary results of prevalence of hypovitaminosis D in a group of patients and proposes a oral supplement therapy effective in correcting hypovitaminosis in a short time, without side effects.

METHODS

243 patients (aged 26-93; 67 males) were enrolled at this study. We evaluated plasma levels of 25-hydroxyvitamin D [25(OH)D] with the following cut-off values: <10 ng/ml or <0-25 nmol/L (deficient), 10-30 ng/ml or 25-75 nmol/L 30-50 (insufficient) and > 30 ng/ml or > 50 nmol/L (normal). The first 73 patients with hypovitaminosis D received at baseline 25,000 IU (Cholecalciferol) per os twice a month (Tp.A). The next patients (Tp.B) at baseline received a loading dose of 50,000 IU once a week for 8 weeks, followed by a maintenance dose of 25,000 IU twice a month.

RESULTS

hypovitaminosis D is a widespread condition (i.e., 82.3%) not only in elderly (75.6% of 75 patients aged <65 yrs and 86.5% of 168 subjects aged >65 yrs). Preliminary results at 6 months show that Tp.B is more effective in correcting hypovitaminosis D (baseline 14.4 ± 5.3 ng/ml; 24 wk 43.3 ± 14.7 ng/ml; p<0.0001).

CONCLUSION

hypovitaminosis D is an important public health problem. We believe it is important to quickly achieve normal Vit. D plasma values in order to produce pleiotropic effects.

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.

Atrial fibrillation (AF) and cognitive impairment in the elderly: a case-control study

AF is able not only to increase the risk of cognitive decline due to acute cerebrovascular events, but also to reduce cardiac output, with the consequence of impaired cerebral perfusion. The aim of this study was to evaluate the association between AF, dementia and depression in patients with negative anamnesis for past strokes. Our sample included 26 patients with a diagnosis of AF (paroxystic, persistent, permanent) and 31 patients with sinus rhythm, enrolled as controls. All selected patients underwent a Multidimensional Geriatric Assessment in order to investigate cognitive and behavioral functions. Statistical analysis of results showed a greater frequency of latent cognitive impairment in patients with AF, even in the absence of memory disorders. As a matter of facts, AF patients showed Mini Mental State Examination (MMSE) scores significantly lower than those with sinus rhythm (p<0.05) and Geriatric Depression Scale (GDS) scores higher than those without AF, evidencing a greater risk of depression too (p<0.02). Results showed a statistically significant association between AF, depression and cognitive impairment in early stage. In conclusion, AF is not only associated with the risk of developing cognitive impairment, but it can also be considered as a risk factor for dementia and depression, even in the absence of medical history of past stroke.

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.

Impact of therapy with alpha-lipoic acid (ALA) on the oxidative stress in the controlled NIDDM: a possible preventive way against the organ dysfunction?

There is a growing evidence that excess generation of highly reactive free radicals, largely due to hyperglycemia, causes oxidative stress, which further exacerbates the development and progression of diabetes and its complications. The purpose of this study was to evaluate the impact of ALA on lipid profile, oxidative pattern and inflammation in patients with controlled non-insulin dependent diabetes mellitus (NIDDM). ALA, 400mg/day was investigated in NIDDM patients over a period of 4 weeks using a randomized, placebo-(PLA)-controlled study with two parallel groups. The marker of oxidative stress was the concentration of reactive oxygen metabolites, evaluated using a commercially available test, called d-ROMs test, and the biological antioxidant potential (BAP); besides, the lipid profile (total cholesterol=TC, high-density lipoprotein-cholesterol = HDL-C; low-density lipoprotein-cholesterol=LDL-C, and triglycerides=TG) and the C-reactive protein (CRP), marker of inflammation were measured at the beginning and at the end of the treatment. A total of 14 patients were randomly assigned to the two groups. ALA was safe and well tolerated in the only oral daily administration. The d-ROMs test (p=0.03) and HDL-C (p=0.04) showed a significant difference between the two groups. BAP (p=0.06) tended to be higher in the treated patients, while LDL-C (p=0.07) presented a moderate decline. There were no significant differences in TC (p=0.65), TG (p=0.78) and CRP (p=0.96) between the ALA and PLA groups. ALA therapy appears to reduce significantly d-ROMs and to improve HDL-C value, especially in men with metabolic syndrome treated with oral hypoglycemic drugs. These findings will be useful in patient selection in future clinical trials with ALA in long term studies.

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.

The treatment of hypertension with telmisartan in the sphere of circadian rhythm in metabolic syndrome in the elderly

This study compares the efficacy of telmisartan with that of valsartan and ramipril in reducing blood pressure (BP) over 24 hrs in the elderly patients with metabolic syndrome (MS). This prospective and open label study analyzed a sample of 60 patients over 65 years of age with hypertension and with MS. At the beginning the BP was monitored by a 24-hr ambulatory blood pressure monitoring (AMBP). Following this, the 60 patients were divided into 3 groups of 20, to each of which was prescribed, respectively, telmisartan, valsartan and ramipril to take for 12 weeks. The drugs were to be taken at 9.00 a.m. Later on the doses were increased. After 12 weeks of therapy, BP was monitored by a 24-hr AMBP. The use of telmisartan caused a greater reduction of the BP in the final 4-6 hours of the period between the 1st administration of the drug and the next one, these last 4-6 hours being those when cardiovascular and cerebrovascular accidents are more frequent (between 6.00 and 10.00 a.m.). Comparing to valsartan and ramipril, telmisartan results in excellent pressure control during the last 4-6 hours between the 1st administration of the drug and the next one.

Exaggerated morning blood pressure surge and cardiovascular events. A 5-year longitudinal study in normotensive and well-controlled hypertensive elderly

Cardiovascular events (CE) occur most frequently in the morning hours in hypertensive subjects. We studied the association between the morning blood pressure (BP) surge and CE in prognosis of 10 normotensive and 32 well-controlled hypertensive elderly, in whom ambulatory BP monitoring was performed and who were followed prospectively for 5 years. The morning surge (MS) of BP was calculated as mean systolic BP during 2h after awakening--mean systolic BP during 1h that included the lowest sleep BP. During an average of 60 months, five CE occurred. When the patients were divided into two groups according to MS, those in the top terzile (MS group; MS> or =34 mmHg, n=14) had a higher prevalence of CE (5 versus 0, p=0.001) during the follow-up period, than the others (non-MS group; MS<34 mmHg, n=28). The logistic regression analysis showed the MS sleep-trough surge as predictive variable of CE (odds ratio, OR=0.794, p=0.022). In conclusion, in older normotensives and well-controlled hypertensives, a higher BP MS is associated with vascular risk independently of clinical and ambulatory BP. Reduction of the MS could thus be a therapeutic target for preventing vascular events also in non-hypertensive patients.

The Marigliano–Cacciafesta polypathological scale: A tool for assessing fragility

The aim of our studies was to establish a standard method of assessment that allows an early identification of frailty in the elderly, i.e., to predict who are at risk of developing disabilities, in order to be able to intervene with preventive global and individualized measures. A new multidimensional scale called Marigliano-Cacciafesta polypathological scale (MCPS) was used on 180 elderly people, together with the Barthel index (BI), the global evaluation functional index (GEFI), the geriatric depression scale (GDS), the mini mental state examination (MMSE), the mini nutritional assessment (MNA), and the Tinetti test. A strongly significant statistical correlation was found between the MCPS and the nutritional state, mood level, motor functionality, level of disability and global functionality. As the fragile patients are at a risk to develop disabilities, we think that our scale can be a significant contribution to the multidimensional geriatric assessment (MGA), aimed at identifying and quantifying the parameter of fragility of each patient, an information which should be known, if we intend to introduce preventive measures.

Carvedilol in elderly patients with chronic heart failure, a 12 weeks randomized, placebo controlled open trial

The encouraging results of recent multicenter clinical trials conducted in the US on the effect of carvedilol therapy in patients with chronic heart failure, prompted us to verify its tolerability in a group of elderly patients. For the open, randomized, placebo-controlled study, we selected 40 patients (28 men and 12 women, mean age 76.8+/-5.9 years) with mild, moderate or severe chronic heart failure. Exclusion criteria included dementia, chronic hepatitis, renal failure, severe vascular disease and respiratory failure. All patients were receiving treatment with digitalis, furosemide and ACE inhibitors. The study lasted 12 weeks. During the first week, all subjects received oral placebo or carvedilol, at a dose of 6.25 mg twice daily. The twice daily dose was then increased to 12.5 mg during weeks 2-4 and to 25 mg from weeks 5-12. At 0, after the 2 weeks of run-in, 4 and 12 weeks patients underwent assessment of systolic and diastolic blood pressure, heart rate, left ventricular ejection fraction, cognitive status and functional ability. Our findings indicate that elderly patients with congestive heart failure tolerate carvedilol therapy well. Carvedilol slightly improves heart function without altering functional or cognitive ability. A larger-scale trial in geriatric patients is now required to determine whether this treatment will reduce serious morbidity or mortality from heart failure.

Randomized, double-blind, placebo controlled, multicentre study of idebenone in patients suffering from multi-infarct dementia

In this randomized double-blind, placebo controlled, multicentre study on 108 elderly patients with mild to moderate mental deterioration of vascular origin, idebenone - a benzoquinone derivative with a hydroxyalkyl side chain - proved to be therapeutically effective in the treatment of multi-infarct dementia. The oral administration of idebenone 45 mg/day b.i.d. for 120 days significantly improved the scores of the following test in comparison with placebo: Mini Mental State, Randt Memory Test, Gottfries Rating Scale, Token Test, Toulouse Piéron Test, indicating improvements in memory attention and cognitivity. The drug was well tolerated and effective in patients with multi-infarct dementia. No changes in laboratory parameters were observed either before or after treatment.

Idebenone in senile dementia of Alzheimer type: a multicentre study

Idebenone is a new cerebro-active drug, effective in dementia disorders, particularly indicated in primary degenerative dementias, i.e. Alzheimer's disease. This new molecule acts as an electron trapper and a free radical scavenger protecting mitochondrial membranes from lipid peroxidation. A multicentric, double-blind trial of idebenone (45 mg twice daily orally) vs. placebo was carried out on 102 elderly patients affected by Alzheimer-type dementia of mild or moderate severity. Idebenone was administered for 4 consecutive months, 45 mg twice daily. Clinical evaluations were performed at the time of enrollment (t0) and monthly thereafter (t30, t60, t90 and t120) and at follow-up (t150 ). Tolerability to idebenone treatment was good and was associated with a statistically significant improvement of memory, attention and behaviour. It is worthwhile noting that these cognitive and behavioral findings were observed after the first month of treatment with enhancement evident in the following period.

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 use of colony stimulating factors in elderly patients with cancer

Hematological toxicity is the most common and the most frequent fatal complication of chemotherapy. It is observed with increased frequency with age, it is a significant independent predictor of the development of febrile neutropenia, and may contribute to a reluctance to administer chemotherapy in the elderly patient population. The authors analyze published data on effectiveness and results of the use of colony stimulating factors for preventing and treating elderly patients affected by tumors during chemotherapy.

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.

BEHAVIORAL DISTURBANCES IN ALZHEIMER’S DISEASE: A NON-PHARMACOLOGICAL THERAPEUTIC APPROACH

Behavioral disturbances in patients with dementia are among the primary causes of institutionalization. Although the majority of authors agree that such symptoms are well controlled with non-pharmacological support, almost all studies have been focused on symptomatic drug therapy (typical or atypical neuroleptics). The aim of our study was to evaluate the reduction of psychiatric symptoms revealed with the test called empirical behavioral pathology in Alzheimer disease (E-Behave-AD) in a population of patients with AD whose caregivers underwent training to learn various communication strategies to utilize with family members. We evaluated 35 patients with AD (18 males, 17 females, average age 76.5 +/- 5.9 years). Of these patients, 18 (9 males, 9 females, average age 75.1 +/- 6.5 years) were relatives of caregivers who underwent training for six months, four group meetings and two individual ones. During the training, caregivers learned about the possibility of communication with persons with AD. They were taught how to interact with the AD patients in various phases of the illness and how to utilize effectively both verbal and non-verbal language. Other 17 patients (9 males, 8 females, average age 76.1 +/- 4.9 years) were followed as a control group. During the period of observation, all patients were given rivastigmine or donezepil. The two groups were homogenous for age, sex, antipsychotic drug therapy, and initial scores on mini-mental state examination (MMSE), activity of daily living (ADL), instrumental activity of daily living (IADL), and E-Behave-AD. After six months, we evaluated the patients with an analogous battery of tests. The analysis of data proceeded from the verification of homogeneity of test subjects and of the control group with t-test for non-paired data. We used the chi2 statistics to compare the qualitative variables between test subjects and the control group. For all statistical tests, a p < 0.05 was considered significant. In the group of patients with caregivers who underwent training, a statistically significant decrease in the E-Behave-AD score (p < 0.001) was observed after six months (7.7 vs. 10.5; p < 0.001). There was no statistically significant modification in the scores for the ADL, IADL, and MMSE (ADL 4.7 vs. 4.3, p = 0.09; IADL 3.2 vs. 3.1, p =0.4; MMSE 17.3 vs. 15.1, p = 0.1). Numerous evidences in literature underline the centrality of the language deficit in dementia, particularly in AD. A re-establishment, even if partial, of the channels of communication between AD patients and doctors, as well as between patients and caregivers, can reduce the frequency and intensity of behavioral disturbances in persons with AD.

Circadian rhythm of some parameters of body composition in the elderly investigated by means of bioelectrical impedance analysis

We studied the within-day determinations of some body composition (BC) parameters in clinically healthy elderly subjects with the aim of investigating their circadian rhythms (CR), which are known to vary in a circadian manner in clinically healthy young adults. The study involved six non-smoking, clinically healthy elderly males (mean age: 75 +/- 4 years; mean weight: 71.07 +/- 10.26 kg; mean height: 170 +/- 5 cm, mean BMI: 24 +/- 1 kg/m2). The BC parameters were determined by means of bioelectrical impedance analysis (BIA) at 2-hour intervals during the day and night, with the subjects lying horizontally in bed. The time-qualified BC estimates were analysed using the Cosinor method. The analysis revealed that the healthy elderly subjects had lost the CR of a number of the BC parameters, including fat body mass, cell body mass, extracellular body mass, total body water, extracellular body water, intracellular body water, and the Na and K exchangeable pools. However, they still retained the CR of body weight and lean body mass, with the expected nocturnal phase of oscillation. The abolition of the CR of the majority of BC parameters in the elderly suggests that human senescence is characterised by consistent changes in the daily rhythmic patterns of fat, water and electrolyte metabolism.

[Cardiovascular risk factors and diseases in centenarians]

Aging is considered a product of an interaction between genetic, environmental and lifestyle factors. Are centenarians, who have almost arrived at the maximum life-span (120 yrs), free of cardiovascular disease or do they have an increased resistance? How many cardiovascular risk factors are present? We have studied a group of 148 centenarians selected from registered residents of Rome (average age 101.8 +/- 1.9; range 100-108). Their health was assessed through direct 1.5 hour interviews, conducted by physicians with geriatric training at the patient's residence, which includes geriatric assessment scales' submission. The prevalence of cardiovascular disease of our centenarians is 16.7%, represented by heart failure (8%), myocardial infarction (4.7%) and angina pectoris (4%). Among the cardiovascular risk factors, hypertension (31.1%) and hypercholesterolemia are the most frequent, while diabetes is not present. These data, compared with younger samples, point out a lower percentage of cardiovascular disease and risk factors. Moreover centenarians have always conducted a healthy lifestyle (Mediterranean diet, smoking abstention, physical activity, low levels of anxiety and depression). Finally, having identified the golden mean which allows us to carry out a programmed intervention for the prevention of cardiovascular risk factors and diseases, we will be able to increase longevity, allowing a larger number of subjects to reach the maximum human life-span.

Influence of age, the autonomic nervous system and anxiety on QT-interval variability

As QT variability increases and heart rate variability diminishes, the QT variability index (QTVI) - a non-invasive measure of beat-to-beat fluctuations in QT interval on a single ECG lead - shows a trend towards positive values. Increased QT variability is a risk factor for sudden death. Aging lengthens the QT interval and reduces RR-interval variability. In the present study we investigated the influence of aging and the autonomic nervous system on QT-interval variability in healthy subjects. We studied 143 healthy subjects, and divided them into two age ranges (younger and older than 65 years). For each subject we measured two QTVIs: from the q wave to the end of the T wave (QTeVI) and to the apex of the T wave (QTaVI). Both indexes were calculated at baseline and after sympathetic stress. In 10 non-elderly subjects, both QTVIs were determined after beta-adrenoreceptor blockade induced by intravenous infusion of propranolol or sotalol. The QTVI was higher in elderly than in younger subjects (P<0.001). QTVIs obtained during sympathetic stress remained unchanged in the elderly, but became more negative in the younger group (P<0.05). QTeVI and QTaVI at baseline were correlated positively with age (P<0.01) and anxiety scores (P<0.05), but inversely with the low-frequency spectral power of RR-interval variability (P<0.001). QTVIs were higher in subjects with higher anxiety scores. In younger subjects, sotalol infusion increased both QTVIs significantly, whereas propranolol infusion did not. In conclusion, aging increases QT-interval variability. Whether this change is associated with an increased risk of sudden death remains unclear. The association of abnormal QT-interval variability with anxiety and with reduced low-frequency spectral power of heart rate variability merits specific investigation. In healthy non-elderly subjects, acute sympathetic stress (tilt) decreases the QTVI. beta-Adrenoreceptor blockade inhibits this negative trend, thus showing its sympathetic origin. Because a negative trend in QTVI induced by sympathetic stress increases only in younger subjects, it could represent a protective mechanism that is lost with aging.

The unexpected contribution of immunosenescence to the leveling off of cancer incidence and mortality in the oldest old

In this paper the hypothesis that some features of immunosenescence might impact on the levelling off of cancer incidence and mortality in the oldest old will be considered. In fact, the term immunosenescence suggests that a progressive loss of immune system (IS) function occurs with aging. However, the age-related modifications of the IS can be more properly acknowledged as a 'remodeling' characterized by profound structural changes, which modify the functional properties of IS. We suggest that the expansion with age of natural killer cells (NK) and of T cells which progressively acquire phenotypes intermediate between T lymphocytes and NK cells, together with the age-related changes in the production of inflammatory/anti-inflammatory cytokines, such as INFgamma and IL-4, might create an environment unfavorable for neoplastic growth in the oldest old. In this perspective, studies on immunosenescence likely provide insights on mechanisms responsible for the individual capacity to escape from the life-threatening consequences of cancer outgrowth.

Influence of aging and other cardiovascular risk factors on baroreflex sensitivity

OBJECTIVES

To examine the influence of known cardiovascular risk factors (cholesterol, blood glucose levels, arterial pressures, heart rate, and aging) on baroreflex sensitivity.

DESIGN

An observational epidemiological study.

SETTING

Geriatric Division at the Policlinico Umberto Primo, University of Rome La Sapienza.

PARTICIPANTS

Two hundred three subjects whose ages ranged from 9 to 94 years, apparently healthy and free of detectable clinical evidence of atherosclerosis.

MEASUREMENTS

All subjects underwent determination of baroreflex sensitivity by phenylephrine infusion (BSphe), and by a noninvasive method derived from spectral analysis of R-R interval and arterial pressure variabilities (alpha index).

RESULTS

The population, subdivided into tertiles for each variable studied, had lower BSphe values and lower alpha indexes as a function of age, plasma low-density lipoprotein (LDL) cholesterol, and systolic blood pressure. The alpha index was significantly lower in both groups with elevated LDL cholesterol levels than in those with lower levels (II and III vs I tertile, P <.001), whereas BSphe differed significantly only in the two groups who had extreme levels of LDL (I vs III tertile, P <.001). Multiple regression analysis identified a negative association of the alpha index with age (P <.001), heart rate (P <.01), area under the glucose-response curve (P <.001), and LDL cholesterol (P <.01), but of BSphe only with age (P <.001) and heart rate (P <.01).

CONCLUSION

These findings indicate that some risk factors for coronary heart disease adversely influence baroreflex sensitivity.

[Arterial hypertension in very old people. Problems of treatment]

Several epidemiological tests showed that, in the very old, low blood pressure was associated with higher mortality and hypertension with a longer life. But more recent studies, some from our school, and the data from Framingham have clarified that the higher mortality in the very old with low blood pressure is to be attributed to pre-existing pathologies which caused the low blood pressure in the first place. Though specific intervention trials on the very old are not available, the analyses of the results of antihypertensive therapy in the sub-groups of the very old in some trials carried-out with elderly hypertensives suggest the use of pharmacological treatment also in the very old (> 80 yrs), at least for isolated systolic hypertension. The therapy must be based on a careful choice of drugs and carried-out with particular caution to avoid disability from hypertension as well as to avoid side effects which worsen the quality of life of your very old patients.

Influence of aging on cardiac baroreflex sensitivity determined non-invasively by power spectral analysis

Aging reduces cardiac baroreflex sensitivity. Our primary aim in the present study was to assess the effects of aging on cardiac baroreflex sensitivity, as determined by power spectral analysis (alpha index), in a large population of healthy subjects. We also compared the alpha indexes determined by power spectral analysis with cardiac baroreflex sensitivity measured by the phenylephrine method (BS(phen)). We studied 142 subjects (79 males/63 females; age range 9-94 years), who were subdivided into five groups according to percentiles of age (25, 50, 75 and 95). Power spectral analysis yields three alpha indexes: an alpha low-frequency (LF) index of cardiac baroreflex sensitivity that ranges around 0.1 Hz; an alpha high-frequency (HF) index reflecting cardiac baroreflex sensitivity corresponding to the respiratory rate; and alpha total frequency (alpha TF), a new index whose spectral window includes all power in the range 0.03-0.42 Hz. Spectra were recorded during controlled and uncontrolled respiration. Under both conditions, all three alpha indexes were higher in the youngest age group (< or =34 years old) than in the three oldest groups. Notably, alpha TF was significantly higher in younger subjects than in the three oldest groups [14+/-1 ms/mmHg compared with 9+/-1 (P<0.05), 8.1+/-1 (P<0.001) and 8.1+/-1 (P<0.05) ms/mmHg respectively]. BS(phen) showed a similar pattern [12+/-1 ms/mmHg compared with 8+/-0.5 (P<0.001), 6+/-0.5 (P<0.05) and 6+/-1 (P<0.05) ms/mmHg respectively]. No significant differences were found for cardiac baroreflex sensitivity among the three oldest groups. All alpha indexes were correlated inversely with age. The index yielding the closest correlation with BS(phen) was alpha TF (r=0.81, P<0.001). Cardiac baroreflex sensitivity in normotensive individuals declines with age. It falls predominantly in middle age (from approx. 48 years onwards) and remains substantially unchanged thereafter. The elderly subjects we selected for this study probably had greater resistance to cardiovascular disease that is manifested clinically, with preserved cardiac baroreceptor sensitivity.

Neural network analysis in predicting 2-year survival in elderly people: a new statistical-mathematical approach

We designed this study to test the usefulness of artificial neural networks (ANN) in assessing 2-year survival in elderly persons, and to understand the net's logical functioning, thus determining the relative importance of the single biological and clinical variables which influence survival. ANN are statistical-mathematical tools able to determine the existence of a correlation between series of data and, once 'trained', to predict output data given input data. Although ANN have been applied in various areas of medical research, they have only very recently been applied in geriatrics (Cacciafesta et al., 2000. Arch. Gerontol. Geriatr. 31 (in press)). We built up an ANN to investigate how 17 clinical variables relating to a sample of 159 elderly people affect survival, and the possibility of predicting 2-year survival or non-survival for each single subject. When tested on a sample of 20 elderly people, the trained network gave the correct answer in 85% of the cases. We then extracted the mathematical function that the net used for calculating the output (survival) for each set of input data (clinical variables). Using this formula, we investigated how some clinical variables influence 2-year survival: we found that a low serum cholesterol level is an unfavourable characteristic in relation to survival. We conclude-despite the fact that the sample studied was relatively small-that ANN are useful in predicting 2-year survival in elderly people. The mathematical function we obtained from the net seems useful in determining the relative importance of single variables related to survival.

Effects of carvedilol on heart rate and blood pressure variability in subjects with chronic heart failure

In this study we observed that carvedilol administration to patients with heart failure improves hemodynamic function, baroreflex sensitivity, and heart rate variability. These findings contribute to improvement in survival in such patients.

[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.

Event-related potentials in the elderly with new mild hypertension

Hypertension is a risk factor for cerebrovascular diseases (CVD) and cognitive impairment and the relative risk of CVD at every level of blood pressure (BP) is greater among the elderly. We submitted 20 elderly affected by new mild hypertension and 10 elderly normotensives to 24-hour ambulatory BP monitoring (ABPM), to evaluate their cognitive state using the Mini-Mental-State-Examination and to the recording of related acoustic evoked potentials (P300 and N2). We did not find significant differences for P300 latency between hypertensives and normotensives, while N2 latency recording showed a statistically significant protracted value in elderly hypertensives. In these patients we found a significant correlation between the N2 latency and systolic blood pressure values recorded by ABPM. These results demonstrated early functional alterations of cognitive state in elderly hypertensives, that are related to systolic blood pressure and future data might point to an earlier use of therapy.