Metabolic and nutritional approach to older frail people

Frailty is a common clinical syndrome in older adults that carries an increased risk for poor health outcomes including falls, incident disability, hospitalization, and mortality. It is characterized by multisystem dysregulations, leading to a loss of dynamic homeostasis, decreased physiologic reserve, and increased vulnerability to stressors. A large body of literature suggests several important multisystem pathophysiologic processes in the pathogenesis of the frailty syndrome, including chronic inflammation and immune activation, insulin resistance and those in musculoskeletal and endocrine systems. Currently, no effective pharmaceutical interventions have been developed for the prevention and treatment of the frailty syndrome. Conversely, epidemiological and intervention studies suggest that adequate nutrition and physical exercise might prevent or postpone the onset of frailty and related clinical manifestations

A fresh view on string orbifolds

In quantum field theory, an orbifold is a way to obtain a new theory from an old one by gauging a finite global symmetry. This definition of orbifold does not make sense for quantum gravity theories, that admit (conjecturally) no global symmetries. In string theory, the orbifold procedure involves the gauging of a global symmetry on the world-sheet theory describing the fundamental string. Alternatively, it is a way to obtain a new string background from an old one by quotienting some isometry. We propose a new formulation of string orbifolds in terms of the group of gauge symmetries of a given string model. In such a formulation, the `parent' and the `child' theories correspond to different ways of breaking or gauging all potential global symmetries of their common subsector. Through a couple of simple examples, we describe how the higher group structure of the gauge group in the parent theory plays a crucial role in determining the gauge group and the twisted sector of the orbifold theory. We also discuss the dependence of this orbifold procedure on the duality frame.Comment: 57 pages, 4 figures; v2: minor changes, references added; v3: revised abstract and introduction, typos corrected, references added, version accepted for publicatio

Functional changes during hospital stay in older patients admitted to an acute care ward : a multicenter observational study

Objectives: Changes in physical performance during hospital stay have rarely been evaluated. In this study, we examined functional changes during hospital stay by assessing both physical performance and activities of daily living. Additionally, we investigated characteristics of older patients associated with meaningful in-hospital improvement in physical performance. Methods: The CRiteria to assess appropriate Medication use among Elderly complex patients project recruited 1123 patients aged >= 65 years, consecutively admitted to geriatric or internal medicine acute care wards of seven Italian hospitals. We analyzed data from 639 participating participants with a Mini Mental State Examination score >= 18/30. Physical performance was assessed by walking speed and grip strength, and functional status by activities of daily living at hospital admission and at discharge. Meaningful improvement was defined as a measured change of at least 1 standard deviation. Multivariable logistic regression models predicting meaningful improvement, included age, gender, type of admission (through emergency room or elective), and physical performance at admission. Results: Mean age of the study participants was 79 years (range 65-98), 52% were female. Overall, mean walking speed and grip strength performance improved during hospital stay (walking speed improvement: 0.04 +/- 0.20 m/s, p<0.001; grip strength improvement: 0.43 +/- 5.66 kg, p = 0.001), no significant change was observed in activities of daily living. Patients with poor physical performance at admission had higher odds for in-hospital improvement. Conclusion: Overall, physical performance measurements show an improvement during hospital stay. The margin for meaningful functional improvement is larger in patients with poor physical function at admission. Nevertheless, most of these patients continue to have poor performance at discharge

Sarcopenia and malnutrition: impact on the outcome in hospitalized patients

Sarcopenia is a condition caused by a progressive loss of lean body mass and muscle strength, related to aging; this leads to a progressive decrease of physical performance. Sarcopenia is inherently connected with a major risk of disability, hospitalization and mortality. Prevalence of sarcopenia increases with increasing age, in particular among hospitalized geriatric patients, with male dominance. Malnutrition is also very frequent condition in elderly patients during hospital stay and it is involved in the development of sarcopenia. The most common therapeutic approach for both malnutrition and sarcopenia is an increased nutritional support with a protein-rich diet. This narrative review summarises the biological mechanism linking sarcopenia and malnutrition in older hospitalized patients and examines evidence supporting the use of oral nutritional support for the prevention and treatment of malnutrition an sarcopenia in acutely ill medical patients

Delirium in hip fractured patients

The current clinical case concerns the mixed delirium in a 70-year-old man with hip fracture, following a fall at home. In his medical history, the patient reported several comorbidities, among which also sarcopenia. Delirium was already diagnosed by the geriatrician on hospital admission. The patient underwent hip endoprosthesis surgery after 24 hours without any intra-operative complications. However, in the post-operative period delirium persisted, causing a prolonged hospital stay, a delayed physio-therapy rehabilitation with poor functional recovery, and subsequent insti-tutionalization. The prevalence of delirium in older people with hip fracture is extremely high and it is associated with several negative outcomes. Delirium is considered a multifactorial disorder, and, in particular, sarcopenia appears directly linked to the development of delirium. The systematic assessment of sarcopenia should be performed in hospitalized older patients with hip fracture, together with the other predisposing risk factors for delirium, to timely identify people at higher risk for both delirium and disability

Acetyl-cholinesterase-inhibitors slow cognitive decline and decrease overall mortality in older patients with dementia

We evaluated the effect of Acetyl-cholinesterase-inhibitors (AChEIs) on cognitive decline and overall survival in a large sample of older patients with late onset Alzheimer's disease (LOAD), vascular dementia (VD) or Lewy body disease (LBD) from a real world setting. Patients with dementia enrolled between 2005 and 2020 by the "Alzheimer's Disease Research Centers" were analysed; the mean follow-up period was 7.9 years. A 1:1 propensity score matching was performed generating a cohort of 1.572 patients (786 treated [AChEIs +] and 786 not treated [AChEIs-] with AChEIs. The MMSE score was almost stable during the first 6 years of follow up in AChEIs + and then declined, while in AChEIs- it progressively declined so that at the end of follow-up (13.6 years) the average decrease in MMSE was 10.8 points in AChEIs- compared with 5.4 points in AChEIs + (p &lt; 0.001). This trend was driven by LOAD (Delta-MMSE:-10.8 vs. -5.7 points; p &lt; 0.001), although a similar effect was observed in VD (Delta-MMSE:-11.6 vs. -8.8; p &lt; 0.001). No effect on cognitive status was found in LBD. At multivariate Cox regression analysis (adjusted for age, gender, dependency level and depression) a strong association between AChEIs therapy and lower all-cause mortality was observed (H.R.:0.59; 95%CI: 0.53-0.66); this was confirmed also in analyses separately conducted in LOAD, VD and LBD. Among older people with dementia, treatment with AChEIs was associated with a slower cognitive decline and with reduced mortality, after a mean follow-up of almost eight years. Our data support the effectiveness of AChEIs in older patients affected by these types of dementia

Prevalence and impact of polypharmacy in older patients with type 2 diabetes

Background: Polypharmacy is a prevalent condition in older adults, especially those with multiple chronic diseases, and has been largely associated with adverse outcomes, including disability, hospitalizations, and death. Aims: This systematic review focused on diabetes and aimed to investigate the prevalence and impact of polypharmacy in older adults affected by such disease. Methods: Observational (either cross-sectional or longitudinal) or experimental studies investigating the frequency and impact of polypharmacy in older adults with diabetes were identified from scientific databases and grey literature until August 2021. The prevalence and the 95% Confidence Interval (95% CI) of polypharmacy in older people with diabetes were summarized by a random-effects meta-analysis. Results: From a total of 1465 records, 9 were selected for the qualitative synthesis, and 8 for the quantitative synthesis. Most studies defined polypharmacy using a cut-off for the minimum number of medications ranging from 4 to 6 drugs/day. The pooled prevalence of polypharmacy in older people with diabetes was 64% (95% CI 45–80%). Considering studies that used the same definition of polypharmacy (i.e. ≥ 5 drugs/day), the pooled prevalence was 50% (95% CI 37–63%). The between-studies heterogeneity was high. Across the selected studies, polypharmacy seemed to negatively influence both diabetes-specific (poor glycemic control and risk of hypoglycemia) and health-related (risk of incident falls, syncope, hospitalization, and death) outcomes. Conclusion: This systematic review confirms the high prevalence of polypharmacy in older people with diabetes and its strong impact on several health-related outcomes, including mortality. These results strengthen the need to improve care strategies for management of these patients

A moderate 500-m treadmill walk for estimating peak oxygen uptake in men with NYHA class I-II heart failure and reduced left ventricular ejection fraction

Background: Maximal cardiopulmonary exercise testing (CPX) is the gold-standard for cardiorespiratory fitness assessment in chronic heart failure (CHF) patients. However, high costs, required medical supervision, and safety concerns make maximal exercise testing impractical for evaluating mobility-impaired adults. Thus, several submaximal walking protocols have been developed and currently used to estimate peak oxygen consumption (VO(2)peak)in CHF patients. However, these tests have to be performed at close to maximum exercise intensity. The aim of this study was to examine the validity of a 500-m treadmill-walking test carried out at moderate intensity for estimating VO(2)peak in community-dwelling adult and elderly patients with CHF and reduced left ventricular ejection fraction (HFrEF).Methods: Forty-three clinically stable men with HFrEF (age 67.7 +/- 9.2 years, and left ventricular ejection fraction, LVEF 38% +/- 6%) underwent exercise testing during an outpatient cardiac rehabilitation/secondary prevention program. Each patients completed a CPX, and a moderate and self-paced (11-13/20 on the Borg scale) 500-m treadmill-walking test. Age, weight, height, walk time, and heart rate during the 500-m test were entered into prediction equations previously validated for VO(2)peak estimation from a 1000-m walking test in patients with cardiovascular disease and preserved LVEF.Results: Directly measured and estimated VO(2)peak values were not different (21.6 +/- 4.9 vs 21.7 +/- 4.6 mL/kg/min). The comparison between measured and estimated VO(2)peak values yielded a correlation of R = 0.97 (SEE = 0.7 mL/kg/min, P < 0.0001). The slope and the intercept coincided with the line of identity (Passing and Bablock analysis, P = 0.50). Residuals were normally distributed, and the examination of the Bland-Altman analysis do not show systematic or proportional error.Conclusions: A moderate and self-regulated 500-m treadmill-walking test is a valid tool for VO(2)peak estimation in patients with HFrEF. These findings may have practical implications in the context of transitioning from clinically based programs to fitness facilities or self-guided exercise programs in adults and elderly men with HFrEF

A drug-induced microscopic colitis in an older woman: a case report

We presented a case of a 87-year-old woman hospitalized for chronic watery diarrhea, affected by multimorbidities. After excluding other caus-es of diarrhea by biohumoral and microbiological tests, endoscopy was performed without revealing any macroscopic abnormalities, but, at histological examination of random biopsies, the characteristic features of collagenous colitis were found. Lansoprazolo and sertraline, chronically taken by the patient, was discontinued, and budesonide was started with prompt clinical improvement. Collagenous colitis is a rare cause of chronic diarrhea in advanced age, but it should be suspected in patients with polypharmacotherapy, after an accurate differential diagnosis

Relationship between People's Interest in Medication Adherence, Health Literacy, and Self-Care: An Infodemiological Analysis in the Pre- and Post-COVID-19 Era

The prevalence of non-communicable diseases has risen sharply in recent years, particularly among older individuals who require complex drug regimens. Patients are increasingly required to manage their health through medication adherence and self-care, but about 50% of patients struggle to adhere to prescribed treatments. This study explored the relationship between interest in medication adherence, health literacy, and self-care and how it changed during the COVID-19 pandemic. We used Google Trends to measure relative search volumes (RSVs) for these three topics from 2012 to 2022. We found that interest in self-care increased the most over time, followed by health literacy and medication adherence. Direct correlations emerged between RSVs for medication adherence and health literacy (r = 0.674, p &lt; 0.0001), medication adherence and self-care (r = 0.466, p &lt; 0.0001), and health literacy and self-care (r = 0.545, p &lt; 0.0001). After the COVID-19 pandemic outbreak, interest in self-care significantly increased, and Latin countries showed a greater interest in self-care than other geographical areas. This study suggests that people are increasingly interested in managing their health, especially in the context of the recent pandemic, and that infodemiology may provide interesting information about the attitudes of the population toward chronic disease management