The key points for treatment of Parkinsonism in older persons

Signs and symptoms of Parkinsonism have a high prevalence in older persons. Parkinsonism is associated with negative outcomes in the elderly and there is still uncertainty about when and how to start levodopa in these conditions. The diagnosis of idiopathic Parkinson disease is often not pursued in the oldest old. The coexistence of both motor and cognitive impairment is the strongest factor limiting the initiation of treatment with levodopa and/or dopamine agonists in a geriatric setting, given the possibility of producing psychotic symptoms, such as visual hallucinations. It seems reasonable to perform at least one attempt to administer levodopa in older persons with parkinsonism, especially when symptoms and motility disorders are evident, in order to try to obtain an improvement in walking speed and balance. Important signs that should guide treatment for Parkinsonism in older persons are the presence of line-pipe rigidity and cogwheel rigidity

The risk of dysphagia is associated with malnutrition and poor functional outcomes in a large population of outpatient older individuals.

Summary Oropharyngeal dysphagia (OD) is a widespread clinical condition among older adults. Although it represents a risk factor for malnutrition, dehydration and aspiration pneumonia, its assessment and contribution to functional decline is often ignored. The aim of the present study was to estimate the prevalence of OD in a large population of non-institutionalized older people and to evaluate its relationship with malnutrition and physical function. 10-item Eating Assessment Tool (EAT-10) and Mini Nutritional Assessment Short Form (MNA-SF) were used to identify the risk of dysphagia and malnutrition. Short Physical Performance Battery (SPPB) and hand-grip strength were used as functional endpoints. The relationship between risk of dysphagia and functional outcomes was tested in a multivariate regression analysis adjusted for age and sex (Model 1) and for other confounders including Mini Mental State Examination (MMSE) and polypharmacy (Model 2). Mean age of 773 subjects (61.3% female) was 81.97 years. The percentage of participants at risk of dysphagia (EAT ≥ 3) was 30.1%, 37.8% of subjects was malnourished (MNA-S

The Geriatric Patient: The Ideal One for Chest Ultrasonography? A Review From the Chest Ultrasound in the Elderly Study Group (GRETA) of the Italian Society of Gerontology and Geriatrics (SIGG)

OBJECTIVES: To investigate the current evidence on the use of point-of-care chest ultrasonography in older patients and geriatric settings and present the current state of the art of chest ultrasound applications. DESIGN: Special article based on a literature review with narrative analyses and expert clinical knowledge. SETTING AND PARTICIPANTS: All studies performed in a geriatric setting were included. Observational and intervention studies and meta-analyses including participants aged ≥70 years were also considered, even if not specifically focused on a geriatric setting. MEASURES: Data on participant characteristics, diagnostic accuracy of chest ultrasonography, and outcomes were collected for each considered study. Data were analyzed and discussed with a particular focus on the possible applications and advantages of chest ultrasonography in geriatric medicine, underlining the possible areas of future research. RESULTS: We found only 5 studies on the diagnostic accuracy and prognostic relevance of chest ultrasonography in geriatrics. However, several studies performed in emergency departments, intensive care units, and internal medicine wards included a large number of participants ≥70 years old; they suggest that chest ultrasonography may represent a valid aid to the diagnostics of acute dyspnea, pneumonia, acute heart failure, pneumothorax, and pleural diseases, with an accuracy in some cases superior to standard x-rays, especially when mobility limitation is present. Diaphragm ultrasonography may also represent a valid tool to guide mechanical ventilation weaning in older patients with acute respiratory failure. CONCLUSIONS AND IMPLICATIONS: Chest ultrasonography may represent a valid bedside diagnostic aid to the management of acute respiratory diseases in older patients. However, specific evidence is lacking for geriatric patients. Future research will need to focus on defining the reference standards and the diagnostic accuracy for older patients with frailty and multimorbidity, cost-efficacy and cost-effectiveness of the technique, its impact for clinical outcomes, and role for follow-up in the post-acute care

Comorbidities and disease severity as risk factors for carbapenem-resistant Klebsiella pneumoniae colonization: report of an experience in an internal medicine unit

Carbapenem-resistant Klebsiella pneumoniae (CRKP) is an emerging multidrug-resistant nosocomial pathogen, spreading to hospitalized elderly patients. Risk factors in this setting are unclear. Our aims were to explore the contribution of multi-morbidity and disease severity in the onset of CRKP colonization/infection, and to describe changes in epidemiology after the institution of quarantine-ward managed by staff-cohorting

Chest ultrasound in Italian geriatric wards: use, applications and clinicians' attitudes

On behalf of the GRETA (Gruppo di Ricerca sull'Ecografia Toracica nell'Anziano) , Group of the Italian Society of Gerontology and Geriatrics (SIGG) Background and aims. Bedside chest ultrasound has emerged as a versatile and accurate diagnostic tool for the management of respiratory conditions in several clinical settings, integrating traditional imaging. The current utilization of this technique in geriatric hospital wards is still unknown. Our aim was to assess availability, uses and applications of chest ultrasonography in a convenience sample of 25 Italian geriatric wards. Methods. A questionnaire, based on the current literature state-of-theart, was e-mailed to head doctors of geriatric wards of Italian hospitals. The questionnaire explored ultrasound equipment availability, practice of chest ultrasound, expertise of ward physicians, clinical indications, and perceived impact on patient care. Results. Ultrasound equipment was available in 92% of wards, and chest ultrasound was performed in 82% of cases. Among the wards where chest ultrasound was performed, it was considered as routine assessment in only 52% of cases, mainly for diagnosis of pleural effusions (95%) and acute heart failure (89%), assessment of volemic state (79%), and assistance to invasive procedures (79%). It was used in emergency/ urgency assessment of acute dyspnea in only 53% of cases. In most wards, only three or less physicians were able to perform chest ultrasound. In 53% of cases, head doctors declared that they perceived benefits of chest ultrasound in patient care in only selected cases. Conclusions. Chest ultrasound utilization in Italian geriatric wards is inhomogeneous, and the number of trained physicians is still limited. Geriatricians' attitude towards chest ultrasound is generally cautious. Research and training programs are needed to spread the correct use of this technique in geriatric practice

Brief practical clinical diagnostic criteria for the neurodegenerative diseases in the elderly

In the literature there is need of clinical and instrumental characterization of all neurodegenerative diseases. Particular attention deserves the timing of the onset of motor or cognitive symptoms, which is extremely useful issue giving the frequent overlapping between neurodegenerative diseases. Aim of this review is to provide a description of typical clinical and imaging features of all neurodegenerative diseases, especially idiopathic Parkinson's disease (PD) and Alzheimer's disease (AD). Particular attention will be devoted to the cluster of symptoms at the moment of the diagnosis. Based on early starting symptoms (cognitive or extrapiramidal) we will introduce criteria to differentiate AD from fronto-Temporal Dementia (FTD), Lewy bodies dementia (DLB) and Vascular dementia (VaD), and between PD, Vascular Parkinsonism (VP) and DLB. All these diseases are characterized by cognitive deficits. PD will be suspected if cognitive impairment occurs at least one year after the onset of the motor symptoms while VP and DLB are more likely if cognitive deficits and motor symptoms appear simultaneously. Finally, we will focus on parkinsonian signs plus other motor symptoms at the time of the diagnosis. The presence of cerebellar or pyramidal signs, with falls and autonomic dysfunction, with or without cognitive deficit should help to consider potential causes of atypical parkinsonism including cortical-basal degeneration (CBD), multiple system atrophy (MSA) and progressive supranuclear palsy (PSP)

Nutrition and Inflammation in Older Individuals: Focus on Vitamin D, n-3 Polyunsaturated Fatty Acids and Whey Proteins

Chronic activation of the inflammatory response, defined as inflammaging, is the key physio-pathological substrate for anabolic resistance, sarcopenia and frailty in older individuals. Nutrients can theoretically modulate this phenomenon. The underlying molecular mechanisms reducing the synthesis of pro-inflammatory mediators have been elucidated, particularly for vitamin D, n-3 polyunsaturated fatty acids (PUFA) and whey proteins. In this paper, we review the current evidence emerging from observational and intervention studies, performed in older individuals, either community-dwelling or hospitalized with acute disease, and evaluating the effects of intake of vitamin D, n-3 PUFA and whey proteins on inflammatory markers, such as C-Reactive Protein (CRP), interleukin-1 (IL-1), interleukin-6 (IL-6) and tumor necrosis factor \u3b1 (TNF-\u3b1). After the analysis, we conclude that there is sufficient evidence for an anti-inflammatory effect in aging only for n-3 PUFA intake, while the few existing intervention studies do not support a similar activity for vitamin D and whey supplements. There is need in the future of large, high-quality studies testing the effects of combined dietary interventions including the above mentioned nutrients on inflammation and health-related outcomes

The association of serum procalcitonin and high-sensitivity C-reactive protein with pneumonia in elderly multimorbid patients with respiratory symptoms: retrospective cohort study

BACKGROUND: Serum procalcitonin and high-sensitivity C-reactive protein (hs-CRP) elevations have been associated with pneumonia in adults. Our aim was to establish their diagnostic usefulness in a cohort of hospitalized multimorbid patients ≥65 years old admitted to hospital with acute respiratory symptoms.METHODS: With a retrospective cohort study design, all multimorbid patients ≥65 years-old with acute respiratory symptoms admitted to an internal medicine hospital ward in Italy from January to August 2013 were evaluated. Pneumonia diagnosis, comorbidities expressed through Cumulative Illness Rating Scale (CIRS), setting of living, length of stay, serum hs-CRP and procalcitonin at admission were collected for each patient. Data were analyzed with Mann-Whitney's U test and multivariate Cox logistic regression analysis. A Receiver Operating Characteristic (ROC) curve was used to verify each biomarker's association with pneumonia diagnosis.RESULTS: Four hundred fifty five patients (227 M) were included in the study, of whom 239 with pneumonia (138 M, mean age 80 ± 13) and 216 without pneumonia (89 M, mean age 80 ± 14). After adjustment for age and sex, median levels of hs-CRP were significantly higher in patients with pneumonia (116 mg/L, IQR 46.5-179.0, vs 22.5 mg/dl, IQR 6.9-84.4, p < 0.0001), while procalcitonin median levels were not (0.22 ng/ml IQR 0.12-0.87, vs 0.15 ng/ml, IQR 0.10-0.35, p = 0.08). The ROC analysis showed that, unlike procalcitonin, hs-CRP values were predictive of pneumonia (AUC 0.76, 95 % CI 0.72-0.79, p < 0.0001, cut-off value 61 mg/L), even after adjustment for possible confounders including nursing home residence and dementia. Serum hs-CRP levels >61 mg/L were independently associated with a 3.59-fold increased risk of pneumonia (OR 3.59, 95 % CI 2.35-5.48, p < 0.0001).CONCLUSION: In elderly multimorbid patients who require hospital admission for respiratory symptoms, serum hs-CRP testing seems to be more useful than procalcitonin for guiding the diagnostic process when clinical suspicion of pneumonia is present. Procalcitonin testing might hence be not recommended in this setting

Dietary habits in women with recurrent idiopathic calcium nephrolithiasis

Nutrition has been widely recognized to influence the risk of kidney stone formation. Therefore the aim of our study was to assess: a) whether usual diet of women with idiopathic calcium nephrolithiasis (ICN) living in Parma (Northern-Italy) is different compared to healthy controls, b) how their diet differs from Italian National guidelines and c) whether it is related to nephrolithiasis clinical course

Older people with hip fracture and IADL disability require earlier surgery

Background: Hip fractures represent a major challenge for physicians as well as society as a whole. Both poor functional status and delay to surgery are well known risk factors for negative outcomes. We hypothesized that the timing of the operation is more important for frail older people than older people without functional limitations before fracture. Methods: We performed a prospective multicenter cohort study on 806 consecutive patients, 75 years of age or older, admitted with a fragility hip fracture to three hospitals in the Emilia-Romagna Region (Italy). All three hospitals had a comanaged care model, and the patients were under the shared responsibility of an orthopedic surgeon and a geriatrician. Results: Functional status assessed as instrumental activities of daily living was an important predictor of survival after 1 year from fracture. After adjusting for confounders, the hazard ratios per 1 point score of increase from 0 to 8 was 1.30 (95% confidence interval 1.19-1.42, p =. 000). Time to surgery increased 1-year mortality in patients with a low instrumental activities of daily living score (hazard ratios per day of surgical delay 1.14, 95% confidence interval 1.06-1.22, p <. 001) and intermediate instrumental activities of daily living score (hazard ratios 1.21, 95% confidence interval 1.09-1.34, p <. 001) but was an insignificant risk factor in functionally independent patients (hazard ratios 1.05 95% confidence interval 0.79-1.41, p =. 706). Conclusions: Surgery delay is an independent factor for mortality in older patients after hip fracture but only for the frail older people with prefracture functional impairment. If our results are confirmed, a more intensive approach should be adopted for older people with hip fractures who have disabilities. © 2012 The Author