Cancer in the elderly: to screen or not to screen?
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Biomedical subjects
Roberto Bernabei
Publications and source records attributed to Roberto Bernabei.
Potentially reversible risk factors and urinary incontinence in frail older people living in community.
BACKGROUND: urinary incontinence is a common problem among older people living in different community settings. The multifactorial origin of urinary incontinence has been largely addressed and many previous studies have identified several reversible factors associated with incontinence. However, few data exist concerning the potentially reversible causes of this condition among frail community-dwelling older individuals. OBJECTIVE: the aim of the present study is to estimate, in a large population of frail elderly people living in the community, the prevalence of urinary incontinence and to determine physical, social, and psychological factors associated with it. DESIGN: observational study. SUBJECTS AND METHODS: we analysed data from a large collaborative observational study group, the Italian Silver Network Home Care project, that collected data on patients admitted to home care programmes (n=5418). A total of 22 Home Health Agencies participated in this project evaluating the implementation of the Minimum Data Set for Home Care instrument. The main outcome measures were the prevalence and factors associated with urinary incontinence. RESULTS: urinary incontinence was recorded in 51% of patients, and it was more common in women than men (52% versus 49%, respectively; P=0.01). After adjustment for each of the variables considered in this study, three potentially reversible factors were strongly associated with urinary incontinence: urinary tract infection (adjusted odds ratio, 3.46; 95% confidence interval, 2.65-4.51), use of physical restraints (adjusted odds ratio, 3.20; 95% confidence interval, 2.19-4.68), environmental barriers (adjusted odds ratio, 1.53; 95% confidence interval, 1.15-2.02). These associations were consistent in both men and women. CONCLUSIONS: the major finding of our study is that potentially reversible factors were strongly and independently associated with urinary incontinence. Failure to make all reasonable efforts to assess and to treat all these factors among frail elderly people should be considered one of the most important indicators of poor quality of care.
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Lack of association between Alzheimer's disease and Gln-Arg 192 Q/R polymorphism of the PON-1 gene in an Italian population.
Alzheimer's disease (AD) is characterized by deposition of oxidized low-density lipoprotein (LDL) forming the senile plaque and by structural changes and cell death in acetylcholine-producing neurons. Paraoxonase-1 (PON-1) is a secreted protein primarily associated with high-density lipoproteins (HDL) and participates in the prevention of LDL oxidation. PON-1 is also an arylesterase that hydrolyzes paraoxon, an active toxic metabolite of parathion, thus providing protection against organophosphate poisoning and metabolization of environmental neurotoxins that might be responsible for neurodegeneration with aging. Serum levels of PON-1 are genetically determined and strongly influenced by a common polymorphism on the position 192 of the PON-1 gene. The aim of this study was to evaluate whether the polymorphism of the PON-1 gene is associated with AD. We studied 124 Italian subjects affected by probable AD and 135 age- and sex-matched controls. The distribution of PON-1 genotypes was 64 QQ, 46 QR, 14 RR in the AD patients and 57 QQ, 59 QR, 19 RR in the control subjects. No statistically significant difference was found between the two groups in our population (p = 0.130 for homozygous QQ, p = 0.279 for heterozygous QR, and p = 0.502 for homozygous RR). These results suggest that the human Gln-Arg 192 Q/R polymorphism of the PON-1 gene is not associated with AD in an Italian population.
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Occupational therapy for stroke patients: when, where, and how?
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Activities of Daily Living↗
Impact of hospitalization on blood pressure control in Italy: results from the Italian Group of Pharmacoepidemiology in the Elderly (GIFA).
STUDY OBJECTIVES: To evaluate whether hospitalization affects blood pressure control in hypertensive patients, and to identify factors associated with attainment of adequate blood pressure control and with aggressive pharmacologic treatment. DESIGN: Retrospective study. SETTING: Eighty-one hospitals throughout Italy. PATIENTS: A total of 3,304 patients (59% women, 41% men) with a diagnosis of hypertension and uncontrolled blood pressure values at hospital admission. MEASUREMENTS AND MAIN RESULTS: Patients' blood pressures were surveyed during study periods from 1988-1997. Controlled blood pressure was defined according to the sixth report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (systolic < 140 mm Hg, diastolic < 90 mm Hg). Aggressive pharmacologic treatment was defined as an increase in the number of antihypertensive drugs that the patient was receiving at hospital discharge compared with the number of drugs on admission. Adequate blood pressure control was achieved in only 767 (23.2%) patients, but the proportion increased in each subsequent survey Age (odds ratio [OR] for 10-year increase 0.82, 95% confidence interval [CI] 0.76-0.88) and male sex (OR 0.79, 95% CI 0.65-0.94) were associated with reduced likelihood of achieving adequate blood pressure control. In contrast, coronary heart disease (OR 1.38, 95% CI 1.14-1.66), year of survey (1995 vs 1988: OR 1.47, 95% CI 1.19-1.82; 1997 vs 1988: OR 1.27, 95% CI 1.02-1.42), length of hospital stay (medium vs lower tertile OR 1.20, 95% CI 0.96-1.49; higher vs lower tertile OR 1.42, 95% CI 1.13-1.77), and increase in number of antihypertensive drugs prescribed (OR 1.21, 95% CI 1.02-1.42 for one drug increase) were associated with improved blood pressure control. In 1753 (53.1%) patients, the number of antihypertensive drugs increased during their hospital stay. Younger age, fewer drugs on admission, lower comorbidity index, diagnosis of chronic heart failure, lengthy hospital stay, and increasing baseline values of systolic and diastolic blood pressure were associated with aggressive pharmacologic treatment. CONCLUSION: Adequate blood pressure control was achieved in only 25% of patients with hypertension despite a trend toward improvement in recent years. Advanced age was one of the main factors associated with less aggressive pharmacologic treatment and with inadequate blood pressure control.
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The use of atypical antipsychotics in nursing homes.
BACKGROUND: Use of atypical antipsychotics for "off-label" indications, such as behavioral and psychological symptoms of dementia, depression, and bipolar disorder, have been frequently reported, although not systematically studied. We describe the pattern of atypical antipsychotic use among nursing home residents and identify demographic and clinical correlates. METHOD: We conducted a cross-sectional study on 139,714 nursing home residents living in 1732 nursing homes in 5 U.S. states from Jan. 1, 1999, to Jan. 31, 2000. Data were obtained from the computerized Minimum Data Set (MDS) assessment records. RESULTS: Behavior problems associated with cognitive impairment were manifest in 86,514 residents, and, of these, 18.2% received an antipsychotic. Approximately 11% received an atypical antipsychotic, while 6.8% received a conventional agent. Clinical correlates of atypical antipsychotic use were Parkinson's disease (adjusted odds ratio [OR] = 1.57, 95% confidence interval [CI] = 1.34 to 1.84), depression (OR = 1.35, 95% CI = 1.24 to 1.46), antidepressant use (OR = 1.38, 95% CI = 1.27 to 1.49), Alzheimer's disease (OR = 1.21, 95% CI = 1.12 to 1.32), non-Alzheimer dementia (OR = 1.15, 95% CI = 1.07 to 1.24), and cholinesterase inhibitor use (OR = 1.74, 95% CI = 1.52 to 1.98). Severe functional impairment was inversely related to atypical antipsychotic use (OR = 0.76, 95% CI = 0.65 to 0.89). CONCLUSION: Atypical antipsychotics are now used more than conventional antipsychotic agents in U.S. nursing homes. Indications and dosages seem appropriate relative to labeling. Clinical and demographic differences between atypical and conventional antipsychotic users tend to be relatively small, suggesting that other factors may explain the choice of prescribing physicians. The impact of facility factors, economic forces, and physician characteristics needs to be investigated.
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The -174 G/C polymorphism of the interleukin-6 gene promoter is associated with Alzheimer's disease in an Italian population [corrected].
Interleukin-6 (IL-6) is a multifunctional cytokine playing a crucial role in inflammation and tissue injury. A role for this molecule in neurodegeneration and Alzheimer's disease (AD) has been proposed. The aim of this study was to evaluate the association between a common polymorphism of the IL-6 gene promoter and AD in the Italian population. We found that the frequency of the GG genotype was significantly higher in AD patients than controls on both univariate ( rho< 0.0001) and multivariate analysis ( rho< 0.0001). In contrast, the CC genotype seems to be associated with a reduced risk of disease ( rho< 0.0001). Our data indicate that the IL-6 gene polymorphism is associated with AD in Italians and confirm that IL-6 is crucial in the pathophysiology of neurodegenerative disorders.
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A controlled trial of geriatric evaluation.
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Adverse drug reactions and cognitive function among hospitalized older adults.
OBJECTIVE: To explore the relationship between cognitive function and the detection of adverse drug reactions (ADRs) and to evaluate whether cognitive function could influence the association between age and ADRs. METHODS: A total of 16,926 patients admitted to 81 hospitals throughout Italy between 1991 and 1997 were included in the study. ADRs detected the during hospital stay were recorded by a study physician. Patients with a Hodkinson Abbreviated Mental Test (AMT) score <7 at hospital admission were considered cognitively impaired. RESULTS: A total of 1,444 ADRs were diagnosed in 976 patients (5.8% of the total sample). Overall, gastrointestinal complications (18.0% of all ADRs) were the most frequent ADRs, followed by cardiovascular (12.3%) and dermatological/allergic complications (12.3%). An ADR was recorded in 232/4,883 (4.8%) patients with cognitive impairment and in 744/12,043 (6.2%) patients cognitively intact. After adjusting for potential confounders, cognitive impairment was associated with a reduced risk of ADRs (OR 0.70; 95% CI: 0.60-0.83). This result was not consistent for all types of ADRs, since the risk of neuropsychiatric complications was significantly increased among patients with cognitive impairment (OR 2.23; 95% CI 1.40-3.54). The overall rate of ADRs was 5.2% in patients younger than 65, 6.1% in patients between 65 and 79, and 5.8% in those 80 or older. When adjusting for potential confounders, not including the AMT score, age was not found to be significantly associated with ADRs. However, when the variable for the AMT score was introduced into the model, the risk for ADRs significantly increased with increasing age. CONCLUSION: Cognitive impairment is associated with a lower detection rate of ADRs, and it represents a confounder of the association between age and ADRs.
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Association between intercellular adhesion molecule-1 E/K gene polymorphism and probable vascular dementia in humans.
Intercellular adhesion molecule-1 (ICAM-1) is implicated in the pathogenesis of ischemic cardiovascular disorders, including cerebral ischemia. A common polymorphism of the ICAM-1 gene (K469E) has been recently reported. In this case-control study, we evaluated the association between this polymorphism and vascular dementia (VD) by studying 107 patients affected by probable VD and 115 age- and sex-matched controls. The frequency of the EE genotype was significantly higher in VD patients than controls (P=0.009). Logistic regression analysis indicated that the presence of the EE genotype significantly increased the risk of VD (odds ratio 3.25, P=0.024). Our findings support the hypothesis that ICAM-1 plays a role in the physiopathology of ischemic cerebrovascular disorders and suggest that genetic polymorphisms of ICAM-1 might be clinically important in the development and progression of neurodegenerative diseases.
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Health care for older persons in Italy.
The aging of the population, with the ensuing rise in the number of older "clients" of the Health Agencies (15.2% people aged 0-14 vs 16% of those aged 64+ already in 1993), the new prospective payment system and a corporate philosophy were the driving forces that led the local Health Agencies to redesign the long-term care system, shifting resources from the hospital to the community. This shift constitutes a present challenge to the entire National Health Service. Furthermore, the Italian Health Service is also becoming decentralized, reflecting closely the political and administrative division of Italy into twenty regions. Regional authorities assign the available resources according to local needs and often interpret the central government's directives for controlling their health care budgets at their own discretion. As a result, profound interregional differences in health care expenditure occur which may aggravate the pre-existing inequalities between the Italian regions. In the coming years, the main priorities to satisfy the needs of frail elderly people are the following: 1) to adapt the number of rehabilitation beds to the standard of 1 bed for 1000 inhabitants; 2) to guarantee in all Health Agencies the presence of Geriatric Evaluation Units in a position to: perform comprehensive geriatric assessment immediately upon request; design and implement individualized care plans in agreement with general practitioners; determine the services that patients are eligible for; and coordinate the delivery and facilitate the integration process between social and health care professionals; 3) to develop all possible alternatives to hospitalization, chiefly programs of integrated home health care or hospital at home; and 4) to realize the number of beds already funded in skilled nursing facilities (RSA) while decreasing acute beds to 4/1000.
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-174 G/C interleukin-6 gene polymorphism and increased risk of multi-infarct dementia: a case-control study.
The aim of this study was to evaluate the association between the -174 G/C polymorphism of interleukin-6 (IL-6) gene promoter and multi-infarct dementia (MID). We studied a group of 122 patients affected by MID and 134 age- and sex-matched controls and evaluated classical risk factors for MID, as well as the distribution of IL-6 alleles and genotypes by polymerase chain reaction and restriction enzyme analysis. The distribution of IL-6 genotypes was 63 GG, 47 GC, 12 CC in patients with MID and 29 GG, 58 GC, 47 CC in control subjects. The GG genotype was significantly more common in the MID group (P<0.0001), while the CC genotype was more common in control patients (P<0.0001). Logistic regression analysis indicated that the presence of GG genotype significantly increases the risk of MID (odds ratio 9.1 [3.1-26.1], P<0.0001). This study indicates a strong association between the -174 G/C polymorphism of the IL-6 gene and MID. Our data support the hypothesis that IL-6 and inflammatory mechanisms are important in the pathophysiology of the vascular changes responsible for cognitive deterioration.
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Predictors of rehabilitation outcomes in frail patients treated in a geriatric hospital.
OBJECTIVES: To evaluate the effect of medical indicators of health status on functional gain during rehabilitation of frail older patients. DESIGN: Observational study. SETTING: A hospital geriatric rehabilitation department (Catholic University of Rome). PARTICIPANTS: Two hundred forty-four older patients admitted consecutively for rehabilitation after acute illnesses between March 1999 and June 2000. MEASUREMENTS: Patients were evaluated with the Minimum Data Set for Post-Acute Care (MDS-PAC) assessment form soon after the admission and every 2 weeks thereafter. Two summary scales based on MDS-PAC items are designed to describe the performance in personal activities of daily living (ADLs) and the level of cognitive function (Cognitive Performance Scale). To identify predictors of functional recovery, we constructed a multiple logistic regression model having as a dependent variable the improvement of one or more points in the ADL scale. RESULTS: Patients aged 85 and older with cognitive or sensory impairment were less likely to significantly improve physical functioning after an intensive rehabilitation program. However, the cognitive impairment was the only "negative" factor that remained significant in a multivariable model (odds ratio = 0.36, 95% confidence interval = 0.14-0.92) after adjusting for several potential negative predictors. CONCLUSIONS: The results of the present study document that severe cognitive impairment may be considered a negative predictor of functional recovery after a period of intensive rehabilitation. However, the effectiveness of such a rehabilitation program in patients with dementia is controversial. Additional studies are necessary to better clarify the effect of cognitive impairment on the potential recovery of the older subjects after a period of rehabilitation and whether this is influenced by different pathologies.
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Adverse drug reactions as cause of hospital admissions: results from the Italian Group of Pharmacoepidemiology in the Elderly (GIFA).
OBJECTIVES: To determine the prevalence of adverse drug reaction (ADR)-related hospital admissions in an older population, to describe the most common clinical manifestations and drugs most frequently responsible for ADR-related hospital admissions, and to identify independent factors predictive of these ADRs. DESIGN: Multicenter pharmacoepidemiology survey conducted between 1988 and 1997. SETTING: Eighty-one academic hospitals throughout Italy. PARTICIPANTS: Twenty-eight thousand four hundred eleven patients consecutively admitted to participating centers during the survey periods. MEASUREMENTS: For each suspected ADR at admission, a physician, who coded description, severity, and potentially responsible drugs, completed a questionnaire. RESULTS: Mean age +/- standard deviation of the patients was 70 +/- 16. One thousand seven hundred four ADRs were identified upon hospital admission. In 964 cases (3.4% of all admissions), ADRs were considered to be the cause of these hospital admissions. Of these, 187 ADRs were coded as severe. Gastrointestinal complaints (19%) represented the most common events, followed by metabolic and hemorrhagic complications (9%). The drugs most frequently responsible for these ADRs were diuretics, calcium channel blockers, nonsteroidal antiinflammatory drugs, and digoxin. Female sex (odds ratio (OR) = 1.30, 95% confidence interval (CI) = 1.10-1.54), alcohol use (OR = 1.39, 95% CI = 1.20-1.60), and number of drugs (OR = 1.24, 95% CI = 1.20-1.27 for each drug increase) were independent predictors of ADR-related hospital admissions. For severe ADRs, age (OR = 1.50, 95% CI = 1.01-2.23 for age 65-79 and OR = 1.53, 95% CI = 1.00-2.33 for age > or =80, respectively), comorbidity (OR = 1.12, 95% CI = 1.05-1.20 for each point in the Charlson Comorbidity Index), and number of drugs (OR = 1.18, 95% CI = 1.11-1.25 for each drug increase) were the only predisposing factors. CONCLUSIONS: The most important determinant of risk for ADR-related hospital admissions in older patients is number of drugs being taken. When considering only severe ADRs, risk is also related to age and frailty.
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Benzodiazepines and the risk of urinary incontinence in frail older persons living in the community.
OBJECTIVE: Urinary incontinence is a common problem among older persons living in different community settings. The multifactorial origin of urinary incontinence has been largely addressed, and many previous studies have identified several reversible factors associated with incontinence. The aim of this study was to estimate the risk of urinary incontinence associated with the use of oxidative or nonoxidative benzodiazepines. METHODS: We analyzed data from a large collaborative observational study group, the Italian Silver Network Home Care project, which collected data on patients admitted to home care programs (N = 4583). A total of 22 home health agencies participated in the project, which evaluated the implementation of the Minimum Data Set for Home Care instrument. The main outcomes measure was the prevalence of urinary incontinence and the association with benzodiazepine use. RESULTS: A total of 1475 individuals (21% of patients aged 60-74 years and 38% aged >or=75 years) reported urinary incontinence. Users of benzodiazepines had an increased risk of urinary incontinence of nearly 45% (odds ratio [OR], 1.44; 95% confidence interval [CI], 1.12-1.83). The risk seemed to be of greater magnitude for exposure to oxidative agents (adjusted OR, 1.47; 95% CI, 1.09-1.99) than to nonoxidative benzodiazepines (adjusted OR, 1.35; 95% CI, 0.93-1.96). Among the oxidative benzodiazepines, the effect mainly resulted from agents with a long elimination half-life (adjusted OR, 1.75; 95% CI, 1.13-2.72). CONCLUSIONS: The metabolic pathway of the benzodiazepines is a good predictor of urinary incontinence. In frail elderly patients, oxidative benzodiazepines are potentially more harmful than nonoxidative agents. Among oxidative benzodiazepines, the best ones seem to be those with a short elimination half-life.
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Prevalence and risk factors for falls in an older community-dwelling population.
BACKGROUND: Falls are responsible for considerable morbidity, immobility, and mortality among elderly people. The aim of this study was to determine the prevalence of falls and related intrinsic and extrinsic risk factors in a community-dwelling older population. METHODS: An observational study was performed on all patients (N = 5570) admitted from 1997 to 2001 to home care programs in 19 home health agencies that participated in the National Silver Network project in Italy. Patient evaluation was performed through the Minimum Data Set-Home Care (MDS-HC) instrument. RESULTS: A 35.9% falls prevalence was found within 90 days of the patient assessment through the MDS-HC instrument. After adjusting for all potential confounding factors, the logistic regression showed a high increase in risk of falling for those patients who wandered (odds ratio [OR] 2.38; 95% confidence interval [CI] 1.81-3.12) or suffered with gait problems (OR 2.13; 95% CI 1.81-2.51). Patients affected by depression were more likely to fall (OR 1.53; 95% CI 1.36-1.73). Those who lived in an unsafe place with environmental hazards had an increase in the risk of falling (OR 1.51; 95% CI 1.34-1.69). The associations of main risk factors for falls were also evaluated. CONCLUSIONS: Rate of falls among frail elderly people living in the community is very high and frequently correlates with potentially reversible factors. To identify those with higher falling risk, home care staff and general practitioners could use the MDS-HC assessment tool.
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Venous thromboembolism among elderly patients treated with atypical and conventional antipsychotic agents.
BACKGROUND: Some antipsychotic agents have been indicated as a possible risk factor for venous thromboembolism (VTE) in adult patients with psychiatric disorders. The aim of this study was to estimate the effect of atypical and conventional antipsychotic agents on the risk of hospitalization for VTE among elderly patients. METHODS: We conducted a retrospective cohort study on nursing home residents in 5 states. We used data from the Minimum Data Set to identify 19 940 new users of antipsychotic agents and 112 078 nonusers. Hospitalization with VTE as primary discharge diagnosis was determined during a 6-month follow-up period using Medicare inpatient claims. Cox proportional hazards models provided estimates of effect adjusted for confounders. RESULTS: The rate of hospitalization for VTE was 0.91 per 100 person-years. Venous thrombosis accounted for 77.6% of events and 22.4% were pulmonary embolisms. Relative to nonusers, the rate of hospitalization for VTE was increased for users of atypical antipsychotic agents, including risperidone (adjusted hazard ratio [HR], 1.98; 95% confidence interval [CI], 1.40-2.78), olanzapine (adjusted HR, 1.87; 95% CI, 1.06-3.27), and clozapine and quetiapine fumarate (adjusted HR, 2.68; 95% CI, 1.15-6.28). No increased rate was associated with phenothiazines (adjusted HR, 1.03; 95% CI, 0.60-1.77) or other conventional agents (adjusted HR, 0.98; 95% CI, 0.52-1.87). CONCLUSIONS: Atypical antipsychotic agents appear to increase the risk of VTE. However, these events are rare, and in clinical practice the absolute risk should be weighed against the effectiveness of these medications in the elderly population.
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Moderate alcohol consumption and adverse drug reactions among older adults.
PURPOSE: To assess the effect of moderate alcohol consumption on Adverse Drug Reactions (ADRs) among older adults admitted to acute care hospitals and to examine the consistency of this effect across gender and age groups. METHODS: We used the GIFA (Italian Group of Pharmacoepidemiology in the Elderly) database, which includes information on patients admitted to 81 medical centers in Italy. For this study we examined exclusively the ADRs detected at hospital admission that were classified as definite or probable based on the Naranjo algorithm. RESULTS: Among 22,778 participants, 894 were found to have one or more ADRs (3.9%). Gastrointestinal complications (n = 210; 0.9% of the population) were the most frequent ADRs, followed by metabolic/endocrine (n = 156; 0.7%), dermatological/allergic (n = 102; 0.4%) and arrhythmic (n = 78; 0.3%) complications. Diuretics were the most frequent culprit drugs, followed by NSAIDs and digoxin. An ADR was recorded in 383/10,427 (3.7%) non-drinkers and in 511/12,351 (4.1%) moderate drinkers. After adjusting for potential confounders, moderate alcohol consumption was associated with a 24% increased risk of ADRs (OR 1.24; 95%CI: 1.08-1.43). This effect seemed more evident among women (OR 1.30; 95%CI: 1.09-1.55), than men (OR 1.14; 95%CI: 0.90-1.43), while it was similar across different age groups (< 65 years OR 1.28; 95%CI: 0.99-1.66; 65-79 years OR 1.22; 95%CI: 0.98-1.52; > or = 80 years OR 1.20; 95%CI: 0.93-1.56). Considering the most common ADRs, moderate alcohol users presented a significantly higher risk of drug-related headache (OR 3.89; 95%CI: 1.43-10.61) and metabolic/endocrine complications (OR 1.67; 95%CI: 1.19-2.33). CONCLUSIONS: Moderate alcohol intake is associated with an increased risk of ADRs; this effect seems more evident among women than men, and it does not differ across age groups.
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