COPD, restrictive syndrome and inflammation.
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Forced Expiratory Volume↗
Biomedical subjects
R Antonelli Incalzi
Publications and source records attributed to R Antonelli Incalzi.
Verbal memory impairment in congestive heart failure.
Cognitive dysfunction, mainly memory impairment, characterizes congestive heart failure (CHF). Aim of this study was to verify whether: (1) CHF has differential effects on primary and secondary memory; (2) memory dysfunction can be diagnosed by a screening instrument. In a multicenter study we enrolled 369 patients with stable CHF who underwent a structured assessment of verbal memory mechanisms and selected cognitive functions. Performance on some verbal memory indexes (Recency, Rey's immediate and delayed recall, Learning efficiency) progressively decreased from II to IV New York Heart Association (NYHA) class. Rate of forgetting was uniformly high across NYHA classes II-IV. Verbal memory indexes were highly correlated with most nonverbal scores. The Mini Mental State Examination (MMSE) had poor sensitivity and specificity versus primary or secondary verbal memory dysfunction. Therefore, a deficit of both primary and secondary memory is relatively common in CHF but cannot be accurately recognized by a screening neuropsychological test.
Activities of Daily Living↗
Construct validity of the abbreviated mental test in older medical inpatients.
OBJECTIVES: To evaluate validity and internal structure of the Abbreviated Mental Test (AMT), and to assess the dependence of the internal structure upon the characteristics of the patients examined. DESIGN: Cross-sectional examination using data from the Italian Group of Pharmacoepidemiology in the Elderly (GIFA) database. SETTING: Twenty-four acute care wards of Geriatrics or General Medicine. PARTICIPANTS: Two thousand eight hundred and eight patients consecutively admitted over a 4-month period. MEASUREMENTS: Demographic characteristics, functional status, medical conditions and performance on AMT were collected at discharge. Sensitivity, specificity and predictive values of the AMT <7 versus a diagnosis of dementia made according to DSM-III-R criteria were computed. The internal structure of AMT was assessed by principal component analysis. The analysis was performed on the whole population and stratified for age (<65, 65-80 and >80 years), gender, education (<6 or >5 years) and presence of congestive heart failure (CHF). RESULTS: AMT achieved high sensitivity (81%), specificity (84%) and negative predictive value (99%), but a low positive predictive value of 25%. The principal component analysis isolated two components: the former component represents the orientation to time and space and explains 45% of AMT variance; the latter is linked to memory and attention and explains 13% of variance. Comparable results were obtained after stratification by age, gender or education. In patients with CHF, only 48.3% of the cumulative variance was explained; the factor accounting for most (34.6%) of the variance explained was mainly related to the three items assessing memory. CONCLUSION: AMT >6 rules out dementia very reliably, whereas AMT <7 requires a second level cognitive assessment to confirm dementia. AMT is bidimensional and maintains the same internal structure across classes defined by selected social and demographic characteristics, but not in CHF patients. It is likely that its internal structure depends on the type of patients. The use of a sum-score could conceal some part of the information provided by the AMT.
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Construct validity of the 15-item geriatric depression scale in older medical inpatients.
The construct validity of the 15-item Geriatric Depression Scale (sfGDS) has been assessed in selected populations. The aim of this study was to assess the appropriateness of applying the sfGDS to unselected older inpatients. The main component analysis of sfGDS was performed in 2032 medical inpatients (mean age = 76.3 +/- 8.4). sfGDS did not qualify as a unidimensional test. Three factors explained 47.7% of variance and explored the following dimensions: positive attitude toward life, distressing thoughts/negative judgment about the own condition, and inactivity/reduced self-esteem. The internal homogeneity was poor (Cronbach's alpha = .46). A higher fraction of variance was explained in patients independent in all or dependent in > or = 1 activity of daily living (ADL). In older medical inpatients, sfGDS is not a single construct, which prevents the univocal interpretation of the final score. The higher fraction of explained variance in patients with comparable ADL performance probably reflects the dependency of affective from physical status.
Activities of Daily Living↗
Exacerbated chronic obstructive pulmonary disease: a frequently unrecognized condition.
OBJECTIVES: To assess to which extent exacerbated chronic obstructive pulmonary disease (COPD) remains unrecognized in the emergency department, which factors account for misdiagnosis and which are the effects of misdiagnosis on patient's management. DESIGN: Retrospective study and stratified random sampling method as selection criterion. SETTING: University Hospital. SUBJECTS: Eighty patients representative of those discharged from the wards of medicine with a diagnosis of exacerbated COPD and 72 having a discharge diagnosis of coronary artery disease (CAD) were studied. MAIN OUTCOME MEASURES: Degree of concordance between admission and discharge diagnosis; presenting symptoms and signs of patients correctly or incorrectly classified on admission; impact of diagnostic procedures carried out by the physician on call on patient's management. RESULTS: The correct diagnosis was missed on admission in 13/80 COPD and 3/72 CAD patients (chi(2): 5.87, P=0.015). The prevalence of the following presenting features distinguished the 67 COPD patients who were correctly classified on admission from the remaining 13: severe weakness (21 vs. 10, chi(2): 9.53, P=0.002), dyspnea (60 vs. 3, chi(2): 28.75, P < 0.001), and limb oedema (14 vs. 6, chi(2): 3.70, P=0.054). Critical hypoxemia was diagnosed and treated only after admission in 19 COPD patients. CONCLUSIONS: Exacerbated COPD frequently escapes recognition in the emergency room, mainly if severe weakness and limb oedema are its presenting features. Arterial blood gas analysis is not systematically performed in the emergency room and, consequently, oxygen therapy is either not administered or given to selected COPD patients on an empirical basis.
Coronary Disease↗
123I-MIBG radioaerosol lung clearance in COPD patients with fixed and partially reversible obstruction to evaluate the functional status of pulmonary adrenergic innervation.
In order to test the hypothesis that a greater sympathetic activity underlies partial reversibility of the bronchial obstruction in selected patients with chronic obstructive pulmonary disease (COPD), we assessed the pulmonary clearance of inhaled I-meta-iodobenzylguanidine ( I-MIBG) radioaerosol in 10 patients with fixed and nine with reversible obstruction. The clearance of inhaled I-MIBG is known to be inversely related to I-MIBG uptake by adrenergic terminals. Groups were matched for age and judged free from confounding comorbidity. The penetration index did not distinguish between the groups (fixed obstruction, 97.39+/-14.59%; reversible obstruction, 89.09+/-19.95%; P=0.659); this excludes the possibility that the inequality of tracer penetration could affect I-MIBG clearance. The I-MIBG clearance was 140.92+/-7.67 min in patients with fixed obstruction and 151.08+/-31.54 min in patients with reversible obstruction ( P=0.604). In conclusion, COPD patients with fixed and reversible obstruction show comparable binding of the tracer to adrenergic pulmonary receptors. Thus, a greater receptor responsiveness or post-receptor mechanism probably underlies the partial reversibility of bronchial obstruction.
3-Iodobenzylguanidine↗
Changes in nutritional status during the hospital stay: a predictor of long-term survival.
The objectives of this prospective observational study were to assess whether: 1) midarm circumference (MAC), previously shown to predict in-hospital mortality, maintains its prognostic implication after discharge; 2) in-hospital changes in aspecific indicators of the health status are predictors of long-term survival. The study population consisted of 249 patients from the general community [mean age 80 +/- 7 (70-99) years], consecutively discharged from geriatric and medical wards of an acute care hospital. Changes in health status during hospitalization were recorded (dynamic or delta variables) and health-related variables were collected at discharge (discharge variables). The relationship of both sets of variables to survival over a 3-year period was assessed by Cox's proportional hazards regression analysis. The discriminatory efficacy of predictive models was estimated by the Hanley and McNeil method. Survival curves were drawn with the patients alternatively grouped according to the presence or absence of each of the predictive variables. Serum albumin < 3.5 g/dL (hazard rate = 0.57, 95% confidence limits = 0.33-0.96) and dependency in at least one ADL (h.r. = 0.87, c.l. = 0.79-0.98) were found to be associated with increased mortality, and delta MAC (h.r. = 1.03, c.l. = 1.01-1.05), i.e., there was a positive change or no change in MAC from admission to discharge, with increased survival. A slightly weaker predictive model was obtained using only discharge variables. However, Hanley and McNeil's analysis showed that both models were far from achieving the optimal discrimination of high from low risk subjects. Effects on survival of individual variables varied in magnitude and dependency on time. We concluded that measuring in-hospital changes in nutritional status might improve prediction of long-term survival. Attempts should be made to identify variables having the strongest prognostic implications, and to tailor dynamic assessment to the needs of selected categories of patients.
Activities of Daily Living↗
Post-operative electrolyte imbalance: implications for elderly.
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Neuropsychologic effects of carotid endarterectomy.
This study assessed neuropsychologic changes after internal carotid endarterectomy using a design that limited the confounding effects of surgical and anesthesiological stress. Twenty-eight patients (mean age = 65.9 years, SD = 8.4, range 45-79), underwent extensive neuropsychological assessment before and on the seventh day after carotid endarterectomy for symptomatic carotid stenosis greater than 75%. A similarly assessed control group of 30 patients underwent elective orthopaedic surgery. A third cognitive assessment was performed 4 months postoperatively on a subgroup of the study patients. No significant cognitive change occurred in the control group. The study patients showed significant improvement in verbal memory, constructive abilities, verbal attainment, and visual attention; a trend towards further improvement of verbal functions was evident at the late postoperative assessment. No side-specific cognitive change was observed. In conclusion, carotid endarterectomy performed for currently accepted indications significantly improves several cognitive functions.
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Co-morbidity contributes to predict mortality of patients with chronic obstructive pulmonary disease.
The aim of this study was to assess the prognostic role of co-morbidity in severe chronic obstructive pulmonary disease (COPD). A cohort of 270 COPD patients, mean (+/-SD) age 67+/-9 yrs, consecutively discharged from a University Hospital after an acute exacerbation was studied. Mean (+/-SD) forced expiratory volume in one second (FEV1) was 34+/-16% of predicted and FEV1/forced vital capacity (FVC) was 40.5+/-13.8%. The most common co-morbid diseases were: hypertension (28%), diabetes mellitus (14%), and ischaemic heart disease (10%). Clinical, electrocardiogram (ECG), and respiratory function data taken at the time of discharge were collected from the clinical records. The Charlson's index was used to quantify co-morbidity. Follow-up was conducted by means of telephone calls. Multivariate survival analysis was used to identify the independent predictors of death. The median survival of the cohort was 3.1 yrs. Death was predicted by the following variables: age (hazard rate (HR) 1.04; 95% confidence intervals (95% CI) 1.02-1.05), ECG signs of right ventricular hypertrophy (HR 1.76; 95% CI 1.30-2.38), chronic renal failure (HR 1.79; 95% CI 1.05-3.02), ECG signs of myocardial infarction or ischaemia (HR 1.42; 95% CI 1.02-1.96), FEV1 < 590 mL (HR 1.49; 95% CI 0.97-2.27). A score based upon these variables predicted mortality at 5 yrs with a sensitivity of 63% and a specificity of 77%. Selected co-morbid diseases and electrocardiogram signs of right ventricular hypertrophy play a major prognostic role in advanced chronic obstructive pulmonary disease. The clinical assessment of patients with chronic obstructive pulmonary disease should include these important and easily measurable variables.
Age Distribution↗
Nutritional assessment: a primary component of multidimensional geriatric assessment in the acute care setting.
OBJECTIVE: To test the prognostic role of nutritional variables as a component of geriatric multidimensional assessment and to study the effect of hospitalization on nutritional status. DESIGN: Validation cohort study: multidimensional assessment on admission and at discharge and a weekly nutritional assessment. SETTING: General Medicine and Geriatrics wards in an acute-care university hospital. PATIENTS: A consecutive sample of 302 patients aged 79 +/- 6 years, range 70-96 years. MAIN OUTCOME MEASURES: Mortality, longstay (> 29 days), loss of lean body mass as expressed by a negative change in mid-arm muscle circumference (MAMC). RESULTS: Incidence of mortality, longstay, and decreased MAMC was 6.9%, 24.8%, and 64.2%, respectively. According to logistic regression analysis, mortality was independently predicted by preadmission dependency in at least one Activity of Daily Living (odds ratio = 2.08, confidence limits = 1.19-3.65), clinical diagnosis of malnutrition (OR = 1.89, CL = 1.11-3.21), serum albumin < 3.5 g/dL (OR = 1.82, CL = 1.06-3.14). This predictive model allowed us to recognize 75% of the patients at risk of death by targeting 23% of the population. Longstay was independently predicted by stroke (OR = 1.54, CL = 1.01-2.35), clinical diagnosis of malnutrition (OR = 1.41, CL = 1.04-1.93), and more than five comorbid diseases (OR = 1.39, CL = 1.01-1.94). Dependency in at least one ADL was the only independent predictor of decreased MAMC (OR = 1.71, CL = 1.27-2.30). CONCLUSIONS: Nutrition variables are a cardinal component of multidimensional assessment in the acute-care setting. Nutritional status deteriorates during the hospital stay, mostly in physically dependent patients.
Activities of Daily Living↗
Effects of aging and of Alzheimer's disease on verbal memory.
This study aimed to define the verbal memory profiles of very old normal subjects and subjects with Alzheimer's Disease, and to identify verbal memory indices having the highest discriminant power. Forty-three old normal subjects (mean age = 71 years, SD = 3, range = 65-75), 39 very old normal subjects (mean age = 81 years, SD = 4, range = 76-87), and 45 Alzheimer's patients (mean age = 70 years, SD = 5, range = 59-78) received the Rey test of verbal memory and the WAIS-R Digit Span forward and backward. All but one of the indices could distinguish very old from Alzheimer's subjects. A discriminant analysis disclosed a verbal memory profile of Alzheimer type in 15.4% of the very old group and of very old type in 16.2% of the Alzheimer's patients. Rate of forgetting, immediate and delayed Rey indices, and the true positive responses were, in decreasing order, the main determinants of the discriminant function. Thus, all of the components of verbal memory are differently affected by aging and Alzheimer's disease and contribute to define individual verbal memory profiles.
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Continuous geriatric care in orthopedic wards: a valuable alternative to orthogeriatric units.
The aim of this study was to assess whether assigning a geriatrician to provide daily medical care to geriatric patients in the orthopedic ward can improve the prognosis and reduce the length of stay. Time series analysis was performed in two parts: 1) prospective analysis of two years' workload, and 2) retrospective analysis of data collected over the 4 years prior to the intervention. Intervention and control populations were pooled, and the effects of geriatric care and patient-related factors on outcome measures were assessed by logistic regression analysis. All subjects were patients aged > or = 70 years who attended the orthopedic ward in a university hospital in years 1989-90 (studied group: 287 cases) and in years 1985-88 (control group: 474 cases). In the study period, mortality was 8.4% compared to 18% in 1985-86 (p < 0.0006) and 14% in 1987-88 (p < 0.01). The operation rate in the study period was 89.9% vs 83.8% in 1985-86 (p < 0.02) and 81.8% in 1987-88 (p < 0.005). Length of stay was 26.2 +/- 14.4 days vs 32.9 +/- 30.9 days in 1985-86 (p < 0.05) and 26.9 +/- 16.5 days in 1987-88 (NS). Length of stay was more strikingly shortened in the subset of patients with femoral fracture undergoing surgical management (28.5 +/- 12.7 vs 37.6 +/- 32.6 days in 1985-86, p < 0.003, and 30.8 +/- 15 days in 1987-88, p < 0.02). Given the positive relationship between geriatric care and operation rate (o.r. = 1.5, CI = 1.1-1.9), the protective effect of surgical treatment on mortality (o.r. = 0.6, CI = 0.4-0.8) to some extent may mask the collinear effect of geriatric care. We conclude that assigning a geriatrician to assist with the medical care of elderly orthopedic patients in orthopedic wards is associated with increased operation rate, decreased mortality and shortened length of stay.
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Post-operative electrolyte imbalance: its incidence and prognostic implications for elderly orthopaedic patients.
In order to assess incidence and prognostic implications of post-operative electrolyte disorders for elderly patients, 180 patients aged 79.5 +/- 6.8 years, range 70-96 years, admitted to a geriatric-orthopaedic liaison service were prospectively followed from admission to discharge or death. The association of age, basic medical conditions, type of anaesthesia and perioperative complications with post-operative sodium/potassium imbalance and fatality was assessed by logistic regression analysis. The incidence of post-operative electrolyte imbalance and fatality was 15% and 8.8%, respectively. Electrolyte imbalance was independently predicted by spinal anaesthesia [odds ratio (OR) = 2, confidence limits (CL) = 1.24-3.19], multiple pathology (OR = 2, CL = 1.1-3.58), use of cathartics (OR = 1.76, CL = 1.05-2.91) and intra-operative complications (OR = 1.7, CL = 1.03-2.88). Death was predicted by electrolyte imbalance (OR = 2.32, CL = 1.21-4.43), post-operative noninfective complications (OR = 2.3, CL = 1.09-4.84) and age greater than 79 years (OR = 1.17, CL = 1.06-1.3). Post-operative electrolyte imbalance is a marker of very frail medical status and a risk factor for death among elderly orthopaedic patients.
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Unrecognized dementia: sociodemographic correlates.
Eighteen geriatric patients, aged 77 +/- 8 years, in whom a diagnosis of dementia was formulated during an unrelated hospital stay, were studied to clarify why dementia had not been detected at an earlier stage. The control group was composed of 20 patients aged 79 +/- 11 years with a comparable degree of cognitive impairment who had been recognized 1-3 years previously. The index group was characterized by a lower formal education (5.2 +/- 3.7 years vs 8.5 +/- 4.7 years, p < 0.05), and higher prevalence of subjects living in rural areas (50% vs 10%, p < 0.006); other sociodemographic variables (age, sex, marital status, employment before retirement) could not distinguish the groups. A multivariate logistic regression analysis showed that the end point late diagnosis was significantly correlated with the independent variables, rural residence (odds ratio = 4.65, C.I. = 1.7-12.9) and lower occupational role (odds ratio = 3.3, C.I. = 1.2-9.5). A structured interview with relatives of the patients disclosed 3 main reasons accounting for later diagnosis: poor awareness of the problem of dementia; respect for parents and grandparents; and negligible effect of this problem on family life and economy. In the control group, dementia had been diagnosed earlier mostly because of its heavier social and economic impact on the family.
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Right ventricular aneurysm: a new prognostic indicator after a first acute myocardial infarction.
The prognostic implication of a right ventricular aneurysm after a first acute myocardial infarction (AMI) was assessed on a series of 137 AMI patients 12 of whom had a right ventricular aneurysm detected at radionuclide angiocardiography. The follow-up lasted 36 months. Mortality was 50 and 18.4% in patients with and without right ventricular aneurysm, respectively (p less than 0.02). Groups did not differ in age, male-to-female ratio, AMI site, left ventricular ejection fraction (LVEF), peak filling rate (PFR), left ventricular size. A multivariate logistic analysis showed that only three out of ten clinical and functional variables qualified to be independent predictors of death: right ventricular aneurysm (odd ratio = 2.48, confidence limits = 1.21-4.98), LVEF less than 52% (odd ratio = 1.91, confidence limits = 1.03-3.48), abnormal terminal P wave forces (odd ratio = 1.72, confidence limits = 1.07-2.75). The analysis of single case histories did not provide a clue to clarify the reasons accounting for the negative prognostic implication of a right ventricular aneurysm. In conclusion, a significant positive relationship between right ventricular aneurysm and mortality after AMI has been demonstrated; further study is needed to clarify the relevant mechanisms.
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Diaphragmatic paralysis: a difficult diagnosis.
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Low atrial tachycardia as primary cause of the heart failure complicating congestive cardiomyopathy.
A 50-years-old man with severe heart failure was diagnosed to have congestive cardiomyopathy and low atrial tachycardia at a fixed rate of 103 bpm. Conventional therapy for heart failure exerted a beneficial effect but complete clinical improvement was achieved only by reducing the rate of low atrial tachycardia with amiodarone. This suggests that in this situation tachycardia itself played a main role in the genesis of hemodynamic derangement.
Amiodarone↗