Characteristics of Nondisabled Older Patients Developing New Disability Associated with Medical Illnesses and Hospitalization

OBJECTIVE: To identify demographic, clinical, and biological characteristics of older nondisabled patients who develop new disability in basic activities of daily living (BADL) during medical illnesses requiring hospitalization. DESIGN: Longitudinal observational study. SETTING: Geriatric and Internal Medicine acute care units. PARTICIPANTS: Data are from 1,686 patients aged 65 and older who independent in BADL 2 weeks before hospital admission, enrolled in the 1998 survey of the Italian Group of Pharmacoepidemiology in the Elderly Study. MEASUREMENTS: Study outcome was new BADL disability at time of hospital discharge. Sociodemographic, functional status, and clinical characteristics were collected at hospital admission; acute and chronic conditions were classified according to the International Classification of Disease, ninth revision; fasting blood samples were obtained and processed with standard methods. RESULTS: At the time of hospital discharge 113 patients (6.7%) presented new BADL disability. Functional decline was strongly related to patients’ age and preadmission instrumental activities of daily living status. In a multivariate analysis, older age, nursing home residency, low body mass index, elevated erythrocyte sedimentation rate, acute stroke, high level of comorbidity expressed as Cumulative Illness Rating Scale score, polypharmacotherapy, cognitive decline, and history of fall in the previous year were independent and significant predictors of BADL disability. CONCLUSION: Several factors might contribute to loss of physical independence in hospitalized older persons. Preexisting conditions associated with the frailty syndrome, including physical and cognitive function, comorbidity, body composition, and inflammatory markers, characterize patients at high risk of functional decline

L'anemia nel paziente geriatrico: elevata prevalenza di forme da causa multipla e di forme “idiopatiche”

none5Scopo: L’anemia è una condizione frequente nel soggetto anziano. Numerosi studi hanno confermato questo dato sia in soggetti free-living(1) sia in soggetti istituzionalizzati mentre più scarsi sono i dati relativi a pazienti anziani ospedalizzati (2,3). Inoltre nel paziente anziano frequentemente la causa dell’anemia non è identificabile,Alcuni studi epidemiologici, infatti, hanno riportato che in oltre 1/3 dei casi la causa dell’anemia non è identificabile (anemia idiopatica) (1). Scopo di questo studio è stato quindi quello di stimare la prevalenza delle diverse forme di anemia in pazienti anziani ospedalizzati e descriverne le caratteristiche cliniche. Materiali e metodi: Sono stati esaminati retrospettivamente i dati di 1005 pazienti consecutivamente ricoverati presso la nostra U.O. nel periodo gennaio-agosto 2008; criteri d’inclusione nello studio erano età ≥ 70 anni e un periodo di degenza ≥4 giorni. Abbiamo cosi ottenuto un campione di 573 soggetti con età media di 81 anni. L’anemia è stata definita, in base ai criteri OMS, per valori di emoglobina inferiori a 13 g/dl per gli uomini e inferiori a 12 g/dl per le donne. Come cause di anemia sono state considerate: l’anemia sideropenica, l’anemia post-emorragica, le forme da deficit di vitamina B12 e/o acido folico, l’anemia da insufficienza renale cronica, l’anemia da infiammazione cronica (definita in presenza di bassi livelli di sideremia e livelli normali o aumentati di ferritina), l’anemia da patologie ematologiche (mieloma, sindrome mielodisplastica, beta-talassemia eterozigote) e la forma idiopatica (dopo esclusione di tutte le altre forme). Risultati: L’età media del campione era 81.6 anni, il 56% del campione era composto da donne. La prevalenza di anemia era del 58.5%, 64% negli uomini e 54% nelle donne. La prevalenza di anemia aumentava all’aumentare dell’età in entrambi i sessi (p <0.01). Per un sottogruppo di 105 pazienti erano disponibili tutti i dati per la diagnosi differenziale delle diverse cause di anemia. In oltre un terzo di questi pazienti (34.3%) erano riscontrabili due o più cause di anemia, un quarto dei pazienti (25.7%) aveva una forma idiopatica, il 15.2% aveva anemia da infiammazione cronica mentre tutte le altre forme avevano una prevalenza inferiore al 10%. Tra i pazienti con anemia da causa multipla l’89% aveva due cause concomitanti mentre il restante 11% aveva tre cause. Tra le forme da causa multipla le associazioni più comuni erano deficit di vit.B12 e/o folati associato ad anemia post-emorragica (22.2%) e anemia da infiammazione cronica associata a deficit di Vit.B12 e/o folati (19.4%). Per quanto riguarda la gravità dell’anemia, i pazienti con anemia da causa multipla avevano una forma grave (3 o più gr. sotto il cut-off diagnostico) nel 58.3% dei casi mentre nei pazienti con forma idiopatica la frequenza era del 18.5%. Conclusione: Nei pazienti anziani ospedalizzati, l’anemia da causa multipla e l’anemia idiopatica costituiscono il 60% di tutte le forme di anemia. Questi risultati suggeriscono una potenziale inadeguatezza in ambito geriatrico dei comuni algoritmi diagnostici, sottolineando la necessità, per un migliore inquadramento diagnostico e terapeutico, di una ricerca sistematica di tutte le possibili cause.noneSioulis F; Maraldi C; Ceriotti C; Volpato S; Fellin RSioulis, Fotini; Maraldi, Cinzia; Ceriotti, C; Volpato, Stefano; Fellin, Renat

Il diabete mellito come fattore di rischio di disabilità nel soggetto anziano

As older adults make up an increasingly lager proportion of the diabetic population, the spectrum of diabetes complications will likely expand. In addition to the traditional cardiovascular complications, diabetes has been associated with excess risk of a number of clinical conditions typical of the geriatric population including, physical disability, falls, fractures, cognitive impairment, and depression. These conditions are common and will profoundly affect the quality of life of older patients with diabetes. The identification of effective ways for preventing and treating these emerging complications, thus improving quality of life among older diabetic patients, is increasingly becoming a mayor issue in geriatric medicine

Anemia, physical disability, and survival in older patients with heart failure

BACKGROUND: Anemia is common in congestive heart failure, and it has been associated with poor prognosis. The effect of anemia on functional ability in heart failure has not been described. We evaluated the relationship of anemia, physical disability, and survival in patients with heart failure. METHODS AND RESULTS: One-year longitudinal study of 567 non-disabled, hospitalized heart failure patients, age > or = 65 years, enrolled in the Italian Group of Pharmacoepidemiology in the Elderly Study. Anemia was defined according to the World Health Organization criteria. Physical disability was defined as dependence in performing at least 2 basic activities of daily living. After adjustment for disease severity and health-related variables, anemia was associated with higher risk of disability (odds ratio = 2.17; 95% confidence interval [CI] = 1.12-4.24). After stratification according to gender, a strong relationship of anemia and risk of disability persisted in women, but it was reduced in men. Anemic women were significantly more likely to die during the follow-up, even after adjustment for potential confounders (hazard ratio = 2.33; CI = 1.02-5.30). CONCLUSION: Anemia is a predictor of physical disability in older heart failure patients, and in women anemia is associated with increased mortality

Forza muscolare e rischio di declino funzionale nelle BADL e riospedalizzazione dopo ricovero: lo studio Pegaso

none9Scopo: La forza muscolare ha dimostrato essere un potente predittore di mortalità e disabilità nel soggetto anziano e la ridotta forza muscolare rappresenta uno dei criteri per l’identificazione dell’anziano fragile. Nel soggetto anziano la patologia acuta e l’ospedalizzazione rappresentano un importante fattore di rischio per declino funzionale e disabilità.2 Studi epidemiologici hanno dimostrato che la presenza di malattia si associa a riduzione della forza muscolare, suggerendo che questo possa essere uno dei meccanismi alla base della perdita di autonomia associata alla malattia ed alla ospedalizzazione. Tuttavia, sono disponibili pochi dati sul valore predittivo della forza muscolare in pazienti anziani in fase acuta. Scopo di questo studio è stato valutare l’associazione tra forza muscolare della mano e rischio di declino funzionale nelle attività di base del vivere quotidiano (ADL) e riospedalizzazione nei 12 mesi dopo la dimissione da un reparto ospedaliero per acuti. Materiali e metodi: Lo studio longitudinale comprende 84 pazienti di età 65 anni ricoverati per patologie acute, in grado di camminare e senza grave deterioramento cognitivo (MMSE>18). Ciascun paziente, oltre ad una accurata valutazione clinica, è stato sottoposto ad una valutazione multidimensionale comprendente stato funzionale, valutato con il grado di autonomia nelle attività di base (BADL) e strumentali (IADL) del vivere quotidiano, stato cognitivo (MMSE) e livello di comorbilità valutato utilizzando la Cumulative Illness Rating Scale (CIRS). Le misure oggettive di funzione fisica includevano: la forza prensile della mano, misurata mediante dinamometro e la funzione degli arti inferiori, valutata mediante la Short Physical Performance Battery (SPPB: velocità di cammino su 4 metri, tempo impiegato per alzarsi 5 volte da una sedia, test dell’equilibrio). Tali valutazioni sono è state effettuate all’ingresso in reparto, alla dimissione, 7 e 30 giorni dopo la dimissione con visita domiciliare. I pazienti sono stati intervistati telefonicamente a 3, 6, 9 e 12 mesi per ottenere informazioni sul livello di autonomia nelle ADL, sul decesso e su nuove ospedalizzazioni. Ad ogni intervista è stato calcolato un punteggio complessivo di disabilità nelle ADL3. L’analisi statistica è stata effettuata con regressione per misure ripetute e regressione logistica (random-effects regression model e discrete-time survival analysis); la forza muscolare è stata analizzata come variabile categorica utilizzando i terzili (I:28.5 Kg). Risultati: L’età media del campione era 77.1 6.4; il 51.2% era costituito da donne. La forza prensile della mano valutata all’ingresso in ospedale era 24.99.4 Kg e non si modificava significativamente durante il ricovero (valori alla dimissione: 24.69.9). La forza muscolare valutata al momento della dimissione non era correlata con lo stato funzionale nelle ADL nel corso dei 12 mesi di follow-up , mentre era associata al rischio di riospedalizzazione o morte. Dopo aggiustamento per età, sesso, altezza e peso, rispetto ai soggetti appartenenti al terzile più basso di forza, i soggetti appartenenti al secondo e terzo terzile avevano un rischio ridotto di riospedalizzazione o morte (Odds Ratio[OR]:0.43;95%Intervallo di confidenza 95% [IC]:0.18-0.98, OR:0.36;CI:0.13-1.00, rispettivamente; p for trend:0.046). Tale relazione rimaneva significativa dopo ulteriore inclusione nel modello di scolarità, livello di comorbilità e stato funzionale nelle BADL (II OR:0.43;CI:0.18-0.98, III OR:0.36;CI:0.13-1.00, p for trend:0.049). Tuttavia, dopo inclusione nel modello del punteggio SPPB l’associazione perdeva di significatività. Conclusione: Nei pazienti anziani ospedalizzati la misura della forza muscolare al momento della dimissione si associa al rischio di nuovo ricovero in ospedale o morte ad un anno. Questa associazione sembra essere indipendente da altri indicatori clinici, ma non dalla performance agli arti inferiori.noneMaraldi C; Rossi L; Ranzini M; Sioulis F; Cavalieri M; Guerra G; Guralnik JM; Fellin R; Volpato SMaraldi, Cinzia; Rossi, Laura; Ranzini, M; Sioulis, Fotini; Cavalieri, Margherita; Guerra, G; Guralnik, Jm; Fellin, Renato; Volpato, Stefan

Moderate alcohol intake and risk of functional decline: the Health, Aging, and Body Composition study

none10OBJECTIVES: To investigate the prospective relationship between alcohol consumption and incident mobility limitation. DESIGN: Cohort study. SETTING: The Health Aging and Body Composition study, conducted in Memphis, Tennessee, and Pittsburgh, Pennsylvania. PARTICIPANTS: Three thousand sixty-one adults aged 70 to 79 without mobility disability at baseline. MEASUREMENTS: Incidence of mobility limitation, defined as self-report at two consecutive semiannual interviews of any difficulty walking one-quarter of a mile or climbing stairs, and incidence of mobility disability, defined as severe difficulty or inability to perform these tasks at two consecutive reports. Alcohol intake, lifestyle-related variables, diseases, and health status indicators were assessed at baseline. RESULTS: During a follow-up time of 6.5 years, participants consuming moderate levels of alcohol had the lowest incidence of mobility limitation (total: 6.4 per 100 person-years (person-years); men: 6.4 per 100 person-years; women: 7.3 per 100 person-years) and mobility disability (total: 2.7 per 100 person-years; men: 2.5 per 100 person-years; women: 2.9 per 100 person-years). Adjusting for demographic characteristics, moderate alcohol intake was associated with lower risk of mobility limitation (hazard ratio (HR)=0.70, 95% confidence interval (CI)=0.55-0.89) and mobility disability (HR=0.66, 95% CI=0.45-0.95) than never or occasional consumption. Additional adjustment for lifestyle-related variables substantially reduced the strength of the associations (HR=0.85, 95% CI=0.66-1.08 and HR=0.81, 95% CI=0.56-1.18, respectively). Adjustment for diseases and health status indicators did not affect the strength of the associations, suggesting that lifestyle is most important in confounding this relationship. CONCLUSION: Lifestyle-related characteristics mainly accounted for the association between moderate alcohol intake and lower risk of functional decline over time. These findings do not support a direct causal effect of alcohol intake on physical function.noneMaraldi C.; Harris TB.; Newman AB.; Kritchevsky SB.; Pahor M.; Koster A.; Satterfield S.; Ayonayon HN.; Fellin R.; Volpato S.Maraldi, Cinzia; Harris, T. B.; Newman, A. B.; Kritchevsky, S. B.; Pahor, M.; Koster, A.; Satterfield, S.; Ayonayon, H. N.; Fellin, Renato; Volpato, Stefan

Frailty syndrome and skeletal muscle: results from the Invecchiare in Chianti study.

BACKGROUND: Frailty is a common condition in elders and identifies a state of vulnerability for adverse health outcomes. OBJECTIVE: Our objective was to provide a biological face validity to the well-established definition of frailty proposed by Fried et al. DESIGN: Data are from the baseline evaluation of 923 participants aged > or =65 y enrolled in the Invecchiare in Chianti study. Frailty was defined by the presence of > or =3 of the following criteria: weight loss, exhaustion, low walking speed, low hand grip strength, and physical inactivity. Muscle density and the ratios of muscle area and fat area to total calf area were measured by using a peripheral quantitative computerized tomography (pQCT) scan. Analyses of covariance and logistic regressions were performed to evaluate the relations between frailty and pQCT measures. RESULTS: The mean age (+/-SD) of the study sample was 74.8 +/- 6.8 y, and 81 participants (8.8%) had > or =3 frailty criteria. Participants with no frailty criteria had significantly higher muscle density (71.1 mg/cm(3), SE = 0.2) and muscle area (71.2%, SE = 0.4) than did frail participants (69.8 mg/cm(3), SE = 0.4; and 68.7%, SE = 1.1, respectively). Fat area was significantly higher in frail participants (22.0%, SE = 0.9) than in participants with no frailty criteria (20.3%, SE = 0.4). Physical inactivity and low walking speed were the frailty criteria that showed the strongest associations with pQCT measures. CONCLUSION: Frail subjects, identified by an easy and inexpensive frailty score, have lower muscle density and muscle mass and higher fat mass than do nonfrail persons

Anemia and cognitive performance in hospitalized older patients: results from the GIFA study.

BACKGROUND: Anemia represents a major risk factor for adverse health-related events in older persons. The aim of this study was to evaluate the association between hemoglobin levels/anemia and cognitive function in hospitalized older persons. METHOD: Data are from the Gruppo Italiano di Farmacovigilanza nell'Anziano (GIFA) study. Hemoglobin levels (in g/dL) were measured upon admission to hospital; anemia was defined according to the WHO criteria. Cognitive performance was assessed by the Abbreviated Mental Test (AMT) on admission; an AMT score <7 defined cognitive impairment. Logistic regressions and analyses of covariance were performed to evaluate the relationship between cognitive status and hemoglobin levels/anemia. RESULTS: Mean age of the sample (n = 13,301) was 72.0 years. Participants with cognitive impairment presented a higher prevalence of anemia (47\%) compared to those without cognitive impairment (35\%, p < 0.001). Adjusted logistic regressions showed that hemoglobin levels/anemia were significantly associated with cognitive impairment (OR = 0.96, 95\%CI = 0.94-0.99, p = 0.004, and OR = 1.32, 95\%CI = 1.18-1.48, p < 0.001, respectively). Patients with anemia and cognitive impairment at the hospital admission presented a higher number of impaired Activities of Daily Living compared to those with only one or none of the studied conditions (p for trend < 0.001). CONCLUSION: Low hemoglobin levels and anemia are independently associated with cognitive performance in older persons admitted to acute care units

La febbre si associa ad una maggiore mortalitá a breve termine in pazienti anziani con ictus ischemico

Objective: in animal models with cerebral ischemia, an increase in body temperature is associated with a larger infarction size. In patients with acute ischemic stroke body temperature within normal values is associated with lower mortality and few neurological defects. The aim of our study is to verify whether an increase in body temperature is an independent predictor of short term mortality. Methods: data concerning 359 old patients consecutively admitted to Internal Medicine ad Geriatrics university Department for “major” acute ischemic stroke have been collected with regard to clinical history, clinical and neurological examination, and laboratory parameters. Fever has been defined as a body temperature higher than 37° Celsius occurred within the first week after admission to the hospital. Short term mortality (within 30 days) was the main outcome of the study. Results: the overall short-term mortality was 28.3%. Among subjects with fever (136, 37.9%) occurred 52.9% of deceased. Fever was associated with mortality at the univariate logistic analysis (OR = 4.8 IC 95%: 3.1-7.8; p = 0.001). After multivariate adjustment for potential confounders the risk of death was still double in subjects with high body temperature (OR = 2.1 IC 95%: 1.1-4.3; p = 0.002). Conclusions: our study confirm the role of fever as predictor of short-term mortality in old subjects with ischemic stroke. This association seems to be independent of many conditions possibly related with fever or death

Physical exercise and comorbidity. Results from the Fitness and Arthritis in Seniors Trial (FAST).

BACKGROUND AND AIMS: Physical exercise is associated with a lower risk of disability. The impact of comorbidity on the benefits from physical exercise has not been clearly investigated. Elders with comorbidity may benefit from physical exercise to preserve physical function. METHODS: Data are from 435 participants with knee osteoarthritis aged > or = 60 years enrolled in the Fitness and Arthritis in Seniors Trial (FAST), who were randomly assigned to 18-month health educational (HE), weight training (WT), or aerobic exercise (AE) interventions. Comorbidity was defined as the presence of osteoarthritis and > or = 2 clinical conditions. Percent changes in the 6-minute walk test, self-reported disability and knee pain from baseline to 3-, 9-, and 18-month follow-up visits were analyzed according to comorbidity, using analysis of variance. Significances were adjusted using the Bonferroni method. RESULTS: Mean age of the sample was 68.7 years. In participants with comorbidity (n=197), those in the AE intervention showed significant improvement in walking speed, compared to WT and HE groups, since the beginning of follow-up. Subjects with comorbidity in AE and WT groups showed improvement of the disability score at the 3-month follow-up visit compared to those in the HE group. This improvement was maintained at the end of the follow-up by the only AE group compared to the HE one (p=0.06). In participants with comorbidity, the pain score was improved by the AE intervention. CONCLUSIONS: AE and WT interventions improve physical function in individuals with comorbidity. AE improves physical function and knee pain independently of the presence of comorbidity