Archives of gerontology and geriatrics. Supplement最新文献

A Geriatric Home Hospitalization Service (GHHS) has been operating in Torino at S. Giovanni Battista Hospital since 1985. GHHS allows us to perform diagnostic and therapeutic interventions, which are usually made in hospital, also at home. GHHS team includes geriatricians, nurses, physiotherapists, social workers and counselors. Between February 1999 and April 2002, the GHH Service conducted a randomized controlled trial on 109 elderly, demented patients requiring admission to the Hospital Emergency Department (ED)for acute illnesses. Objective of the study was to identify the benefits of the care in a GHHScompared to a general medical ward (GMW) in reducing behavioral disturbances in elderly patients with advanced dementia and in lowering caregiver's stress. Patients were randomly assigned to GHHS (56 patients) or to GMW (53 patients). Both groups were examined using the same protocol and were evaluated on admission and on discharge. All patients had a severe form of dementia as shown by the clinical dementia rating (CDR) scale mean value (3.7 +/- 0.9) with an important functional impairment and a relevant degree of comorbidity.The main reasons for hospitalization were infections, cerebrovascular accidents and malnutrition. Mortality of total sample was 19.3 %, without significant differences in the two settings of care. On discharge, in GHHS patients there was a significant reduction of behavioral disturbances. The use of anti-psychotic drugs was significantly lower in GHHS patients compared to the GMW group (p < 0.001). The stress of caregivers on discharge was reduced only in GHHS group and not in the control ones. In conclusion, we can say that a GHHS continuous support allows us to reduce the family caregiver's stress. When treated at home, demented patients do not have to change their environment or routine and it is possible to have a better control on behavioral disturbances.

In the context of the diseases characterized by cognitive impairment, the appearance of behavioral modifications is frequently observed, in particular agitation and/or aggression. In dementia, cognitive symptoms are often associated with psychiatric symptoms, such as personality, mood, behavioral and "psychotic" disorders, at present defined as behavioral and psychological symptoms of dementia (BPSD), representing the main cause of hospitalization for these patients. Among the different pharmacological classes, justified by the complex genesis of BPSD, the choice of a specific treatment is mainly related with the safety of different molecules, among which atypical antipsychotics are the first choice class.

Senescence is accompanied by an important increase in prevalence and incidence of ischemic stroke. The plasma level of fibrinogen tends to increase with age in the elderly similarly to the prevalence of stroke. The aim of our study was to evaluate the age-related increase in fibrinogen plasma level in the elderly and to assess the presence of eventual differences between normal subjects and patients with previous ischemic stroke associated with precerebral atherosclerosis. Eighty inpatients (41 males and 39 females), consecutively admitted to our Geriatric Unit, were included to this study. The patient group was formed 32 subjects (20 males and 12 females) aged 50-79 years, suffering from cerebrovascular disease with one or several previous ischemic stroke episodes, having occurred at least 1 year earlier. The control group consisted of 48 normal subjects (21 males and 27 females) aged 50-79 years. Both control and patient groups were subdivided into three subgroups, according to their age: Group 1 (50-59 years), Group 2 (60-69 years)and Group 3 (70-79 years). The statistical comparison was carried out by means of the Mann-Whithney nonparametric test. In normal controls, a mild age effect is evident because only Group 3 shows fibrinogen levels significantly higher than those of Group 1. On the contrary, in patients with ischemic stroke, an age effect is already evident between Group 2 and Group 1; of course, also the comparison between patient Group 3 and Group I shows a statistically significant difference. Moreover, the levels of fibrinogen were significantly increased in patient Group 2 and 3 when compared to those of their respective age-matched controls. Our data are in agreement with those already available in the literature and demonstrate that fibrinogen in normal aging changes with age and shows a 19 %increase between age Group 1 and Group 3. Patients with ischemic stroke show an earlier and more evident age-related increase in fibrinogen than normal controls. Even if it is not possible to know, if the increase in fibrinogen is a consequence or not of the ischemic stroke, we can affirm that certainly the increased levels of fibrinogen should be considered as an important risk factor in the elderly for cerebrovascular disease and deserve treatment.

In the present study we assessed the presence and severity of unconventional affective symptoms (apathy, anhedonia and emotional lability) and depression in 33 elderly patients with first ever stroke and evidence of a single supratentorial lesion at neuroimaging. Patients were submitted to neurological, functional, and affective assessment at a mean interval of 2 weeks after stroke onset. Given the putative role of the frontal lobes in the pathogenesis of these symptoms, we also performed a cognitive assessment focused on executive functions. The prevalence of the various affective symptoms was as follows:apathy 15.2 %, anhedonia 6.1 %, emotional lability 48.5 %, depression 57.6 % of cases. Patients had a normal global cognitive level (mean short portable mental status questionnaire: 8.4 +/- 1.0, range 7-10). Apathy and anhedonia showed significant reciprocal correlations and they were also correlated with the executive score and the Barthel index;apathy was also correlated with depression; emotional lability, instead, was correlated only with depression. The study of possible anatomo-functional correlates between unconventional affective symptoms and lesion site did not show significant differences (stroke in the right versus left hemisphere, anterior versus posterior and cortical versus subcortical locations).

Techniques of reality orientation in dementia are widely used around the world and indifferent settings. Nevertheless, after the controversies for adverse effects and frustration,by the new millennium "a new era" is coming on where cognitive rehabilitation "has come of age" and a series of positive results appeared until the fulfillment in the global and person-centered approach. This renewed technique may no more be based only on cognitive psychology but it is necessary to apply a more complete psychosocial approach taking into account also emotional, behavioral and functional domains of the globally considered person. The aims of our study are: (1) To assess the global efficacy on cognitive and affective functions. (2) To detect cognitive subsystems more sensible to our three-phase stimulation program. We studied 34 outpatients, 13 men and 21 women, age range 67-88 years, referred to our Expertise Center, all but one affected by mild cognitive impairment(MCI), suffering from mild dementia (clinical dementia rating, CDR <1). After 20 sessions of formal and complementary activities, a comprehensive improvement of cognition, language,memory and affective functions was observed. Semantic fluency improved with high statistically significant difference. The immediate recall, free or cued, appeared more sensible to stimulation than the delayed one. A correlation between a mini mental state examination (MMSE) low basal score and higher performance after the program was also obtained.

One-hundred-thirty-tree patients with neuropathologically confirmed Alzheimer's disease (AD) were genotyped for the polymorphic regions in the apolipoprotein Eepsilon (APOE)and a new polymorphism in the promoter region of the alpha-1-antichymotrypsin (ACT) gene. The ACT TT genotype was associated with a longer survival of AD patients, and among patients with the APOE epsilon4 allele, this genotype increased the duration of the disease. The ACT TT genotype was also associated with a late age at onset of the disease and a delayed age at death in patients without the APOE epsilon4 allele. This latter group of patients also showed increased levels of synaptophysin from the mid-frontal (MF) cortex area. ACT appears to play complex, multiple roles on AD and to affect synaptic plasticity in the AD brain of patients without the allele APOE epsilon4 allele.

The complexity has been viewed as an obstacle to medical research which, by necessity, depends on reduction. As a consequence, medical science often uses logical reductions in the attempt to understand the various facets of different clinical syndromes.However, such a reduction is not always possible in psychogeriatric syndromes where the clinical and biological complexity is the rule rather than the exception, and to identify correlation of signs and symptoms to a specific disease is often a difficult task. The present paper describes the complex relationships and interactions between the mood, behavior and memory. It is also suggested that the comprehension of psychogeriatric syndromes should not be based only on a separate analysis of these 3 elements (i.e., mood, behavior and memory), but on a multidimensional assessment of their reciprocal and dynamic interactions which may concur in the determination of the outcomes.

The most diffuse questionnaires on health-related quality of life (HRQL) and/or psychological status (PS) consider all subjects older than 74 years, for normative reference values, in a single group without any further separation for age decades. Their authors assume that there are no further age-related differences, since older patients had a severely limited autonomy and lose the capacity of grading the severity of the diseases they are affected. Healthy subjects older than 80, without mental impairment (WMI) present an acceptable HRQL, PS and a perception of health status. No data are available on the oldest patients, carrying chronic diseases, admitted to hospital departments for acute health problems.We collected 46 WMI oldest patients (>/= 80 years), admitted for such troubles. They were investigated by the mini mental state examination (MMSE) and, in random order, the Nottingham health profile (NHP) and the psychological general well-being instrument(PGWBI). Clinical data recordings were carried out by the medical personnel, using standardized forms. The value of any individual domain of each patient was compared to the age - (>/=75-year) and sex-matched control group derived from two large Italian population studies, using the Z-score. Charlson's comorbidity index, the index of coexistent disease (ICED), and the cumulative illness rating scale (CIRS) were also calculated. Patients older than 80 did show difference in NHP domains in comparison with normative values only for social isolation, but presented significantly worse Z-scores in all domains ofPGWBI. A relationship was observed between number of daily medications and Z-scores of physical mobility and energy (NHP). Similarly, vitality (PGWBI) correlated with all comorbidity indices, ICED with positive well-being (PGWBI), pain (NHP) with CIRS subscales. Hospitalized WMI oldest subjects maintain a HRQL quite comparable to normative group of subjects older than 74 years. Furthermore, they showed a preserved correct perception of factors/diseases that possibly affect their psychological status and autonomy.

Cognitive impairment and depression are commonly associated with poor outcomes in geriatric patients. Both are part of the "failure to thrive syndrome" (FTS), that is a combined group of symptoms as a result from progressive functional, mental and nutritional impairment status in older patients. This paper was aimed at evaluating the presence of FTS in the patients who died in a geriatric convalescence unit (GCU) (intermediate care facility) and comparing the characteristics of patients with primary FTS (not associated with an evident identifiable disease) and secondary FTS (associated with an evident identifiable disease). Finally, we wanted to analyze if the presence of cognitive impairment before admission was associated with the type of FTS. We analyzed 78 patients retrospectively. The presence of the next three conditions was necessary to define the FTS: (i) Impaired functional status and malnutrition. (ii) Cognitive impairment and/or depression. (iii) Absence of improvement, after a specific geriatric intervention program during the hospitalization. Functional status for basic and instrumental activities of daily living (ADL and IADL) and the presence of symptoms cognitive impairment before admission were evaluated. Of the 78 analyzed patients, there were 30 (38.4%) with symptoms of FTS. Seventeen of them (56.6%) had a secondary FTS and 13 (43.3%) a primary one. This last group of patients had a significantly higher mean age (84.7 +/- 5.8 vs. 78.6 +/- 7.2; p < 0.02) and before admission they were significantly more dependent for ADL: 10 patients (76.9%) vs. 7 (41.0%) chi2 = 3.833, p < 0.05. A higher proportion of subjects with cognitive impairment before admission was found in the group of patients with primary FTS, than in those secondary FTS, although this difference did not reach statistical significance. Patients with primary FTS seem to be older and more dependent for ADL before admission, than those with secondary FTS.