Cognitive impairment, depression and delirium are problems of high prevalence in older patients. The geriatric convalescence unit (GCU) is a hospitalization facility offering an interdisciplinary geriatric intervention program that may be more appropriate for these patients. This study intended to analyze the functional improvement (FI) in older patients with cognitive impairment, depression and/or delirium admitted to a GCU. A group of 107 patients received specific nurse care, habitually performed in GCU and they also were included in a rehabilitation program. Cognitive impairment, depression and delirium were diagnosed according to standardized protocols. The analyzed variables were: age, functional status (Barthel index) before admission (BBA), at admission (BA) and at discharge(BD), diagnostic categories, cognitive function (mini mental state examination: MMSE) and post-discharge destination. The corrected Heinemann index (CHI) was used to evaluate FI obtained during GCU-stay, where CHI = 100 x (BD-BA)/(BBA-BA), and the efficiency index(El) was used to analyze the relationship between FI and the length of stay in the GCU,where El = (BD-BA)/(days in GCU). According to CHI, patients were divided in three groups. Group I: CHI = 0 or negative (patients who lost functional capacity during hospitalization,those who died or were transferred to hospital owing to acute deterioration. Group II: CHI < 35 % (high FI). Mean age was 77.6 +/- 9.1 years, the diagnostic categories were: fractures/orthopedics 49 (45.7 %), neurological 27(25.2 %), pulmonary/cardiologic 6 (5.6 %) and other cases 25 (23.3 %). Mean MMSE and BA scores were 16.9 +/- 9.4 and 29.6 +/- 18.9, respectively. Post-discharge destinations were:63 patients (58.8 %) returned home, 28 (26.1 %) were definitively institutionalized, 11 (10.2%) died and finally 5 (4.6 %) were transferred to acute care hospital. In-Group I, there were 35 patients (32.7 %) with a mean value of the El = 0.12 +/-1.1; in Group II, 13 (12.1 %) and 0.26 +/- 0.38; in Group III, 59 (55.1 %) and 0.94 +/- 0.97, respectively. In spite of the presence of cognitive impairment, depression and/or delirium, a high proportion of patients (67.2 %)obtained a significant improvement in their functional capacity.35 % (moderate FI). Group III: CHI >/=
Aging of the world population risks to be accompanied by an increase of chronic health problems, and most particularly of mental health problems. To face these problems the organization of care and education in old age psychiatry is still quite low. If at inter -national level the body of knowledge and skills of the psychiatry of the elderly is today enough recognized it is very difficult to convince authorities at national and local level to recognize this discipline as a sub-specialty of psychiatry. Even when some resources exist at local level to support old people with mental disorders, very often these old persons do not look for care as consequence of the prevailing double stigma attached to mental disorders in general and to the end of life in particular. In order to promote changes of this situation, the World Health Organization (WHO) Collaborating Centre of Lausanne realized a WHO-World Psychiatric Association (WPA) consensus meeting and statement on how to reduce the stigma and the discrimination against old persons with mental disorders, as well it has realized a survey in Europe on this specific subject of stigma and discrimination against these old persons. As education is one of the most important components of the strategy to reduce stigma and discrimination, 3 recent developments were done to promote this. The first one is a survey conducted by the section of old age psychiatry of WPA. The second one is the consensus statement on education in psychiatry of the elderly jointly published by WHO and WPA, and finally was the recent publication of a skill -based objectives for the training in the discipline. These efforts will be completed by some actions to strengthen the impact of all these documents.
This study on home care for demented patients is one of the finalized research projects sponsored by the Ministry of Health. The teams involved are: the Home Hospitalization Service (HHS) of S. Giovanni Battista Hospital of Torino, the "Azienda Sanitaria Locale ndegrees 20" (ASL 20) of Alessandria and Tortona and the "Presidio Ospedaliero Riabilitativo Fatebenefratelli" of San Maurizio Canavese (Torino). Aim of the study is to assess the feasibility and usefulness of taking care of elderly demented patients at home and to improve the quality of life of patients and their relatives, involving training experiences and economic help. The Geriatric Department of San Giovanni Battista Hospital started a randomized controlled study on 109 severely demented subjects admitted to the emergency room of the hospital. Fifty-three patients were transferred to the traditional geriatric ward and 56 to the HHS. The team of ASL 20 of Alessandria and Tortona selected and evaluated 45 elderly demented patients living at home. These subjects, stratified for their cognitive and functional impairment, were randomly allocated to two different groups: a group receiving an economic help for one year and a control group. In the first setting of research the degree of dementia was severe, mini mental state examination (MMSE) score was 10.0 +/- 5.2 for patients at home, and 10.5 +/- 6 for the second group. The majority of patients followed at home (78.6%) were discharged, while only 47.2% of the in-patients returned home (p < 0.001). Seventeen out of 53 patients (32.1%) admitted to the traditional ward and only two of home-hospitalization patients had to be sent to nursing home (p < 0.001). The 45 subjects evaluated by the team of ASL 20 were divided into two groups. Twenty-four subjects were allocated to receive a home care allowance. Their functional status was impaired. Their MMSE score was 12.6 +/- 5.4 and clinical dementia rating scale (CDR) score 2.7 +/- 0.9. A control group of 21 subjects (17 women and 4 men) showed similar characteristics as the previously described group.
Hyperhomocysteinemia is a risk factor for dementia but only scanty data exist about its relationship to specific cognitive abilities during normal aging. We recruited 62 healthy and cognitively normal subjects of age 65-91 years from the Conselice Study of brain aging. The following neuropsychological tests were applied (i) The mental deterioration battery (MDB) consisting of 7 parts: the Rey's 15 words immediate and delayed recall, word fluency, sentence construction, Raven's progressive matrices '47, immediate visual memory, freehand copying of drawings and copying drawings with landmarks. (ii) The Prose memory test. (iii) The Corsi block-tapping task. (iv) The mini mental state examination (MMSE) scores. We measured plasma total homocysteine (tHcy), serum folate, vitamin B-12, and plasma vitamin B-6. Multivariate-adjusted linear regression analysis showed statistically significant negative association of plasma tHcy with scores at MMSE (b= -0.012, p < 0.001) and word fluency (b = -0.009, p = 0.021). A non-significant trend towards a negative association was also found for sentence construction (b = -0.006, p = 0.076). One can conclude that in healthy elderly subjects, increased plasma tHcy is correlated to poorer performance at a specific measure of language abilities being compromised in both vascular and Alzheimer's dementia. The study suggests that plasma tHcy could be an early marker of cognitive impairment.
We studied mood disorders (MD) and psychotic symptoms (PS) in patients with fronto -temporal dementia (FTD) and Alzheimer's disease (AD) by means of different diagnostic instruments. These were: a subjective scale (subsets of survey psychiatric assessment schedule: SPAS), an objective scale (subsets of neuropsychiatric inventory: NPI) and a projective task (Wartegg completion task: WCT). A general tendency of NPI to over estimate the presence of symptoms compared to SPAS was observed, but distribution and severity of symptoms were quite homogeneous in the two dementia-groups, independently of the diagnostic scales. At variance with the scales, the WCT showed a more severe impairment in FTD than in AD. The regression analysis selected neuropsychological models able to predict behavioral disorders only in FTD, in particular, a planning deficit predicted PS. These data confirm the hypothesis that a damage in the frontal areas constitutes the neurobiological basis of PS in degenerative brain diseases. Furthermore, they suggest that mostly in FTD, behavioral disorders, as well as cognitive deficits, should be considered a direct expression of neural damage.
Balance disorders are frequent with aging. They are particularly important because they decrease social autonomy of the aged subjects and they often provoke falls. The cause is always multifactorial. There is evidence that aging affects multiple sensory inputs, as well as the muscoloskeletal system and central nervous system ability to perform sensorimotor integration. For the evaluation of decreased balance skills in elderly, a specific questionnaire has been prepared, in order to identify high risk of falling called falling risk inventory (FRI) questionnaire, and a complex psycho-sensory-motor test has been studied by means of posturography, in order to detect specific vestibular impairment. Regarding ethiopathogenesis of balance disorders in aged subjects, because the decline of behavioral and cognitive performances are due also to decline of biological rhythm control, the role of melatonin (the hormone regulating circadian rhythms, being strictly connected with cerebellar function, and it is well known that cerebellum acts in elderly both at motor and cognitive regulation. The goals of the present paper are: (i) To present a self-administered FRI questionnaire aimed at identifying possible causes of falls and quantifying falling risk in aged. (ii) To validate posturography as a specific test to investigate vestibular involvement in elderly in correlation with FRI. (iii) To present a complex behavioral test (NT) aimed at evaluating both spatial orientation and spatial memory in elderly, factors involved into the genesis of complex dizziness and unsteadiness. (iv) To evaluate the role of melatonin in cognitive involvement in dizzy, old subjects due to the functional correlations between circadian rhythms, cerebellum balance disturbances and cognitive disorders. General conclusions are: FRI correlates with falling risk. Posturography identifies specific vestibular impairments correlated to balance disorders and elderly falls. Spatial orientation is altered in about 40% of dizzy patients but no significant differences are revealed in melatonin rhythm. Spatial memory is highly altered only in subjects with inversion of circadian melatonin rhythm it is possible to hypothesize that the alteration of the normal circadian melatonin rhythm plays some role in the genesis of dizziness in a subpopulation of patients.
The study was aimed at identifying recovery possibility in elderly patients suffering from a first ever stroke and admitted to rehabilitation with concomitant high disability. From 1998 to 1999 one hundred elderly patients were entered consecutively into this study. Disability was measured by functional independence measure (FIM). The FIM value at admission had a median value 23, which indicated a very high post-stroke disability. At discharge the FIM median value was 33. After one year 41 patients were at home. Their median FIM value was 62.5. Thirty-one patients had died over the interval. The death was mainly due to a new stroke, cardiac diseases or acute pneumonia. Six patients were in a nursing home and 22 could not be studied at follow-up.
The Massa Lombarda program (MLP) is the first step of a European multi-center program, promoted and coordinated from Bologna University's Academic Spin off Health Research and Development, which attempts to manage advanced sanitary research in general population. The instant individual definition (IID) study is the first phase of the program concerning the study of risk factors (RF) and early diagnosis of coronary heart disease (CHID), through a new diagnostic technology called myocardial perfusion scoring system (MPS). The study consists of a longitudinal observational epidemiological investigation of adult population (above 25 years of age) resident in Massa Lombarda (Ravenna), with the survey of social and biological parameters. The elderly part of the population (1000 subjects above 76 years) was submitted to a more complex analysis, as part of the study on health status in European aging populations, aimed at revealing the determinants influencing the healthy aging, and at identifying their impact on mortality, cardiovascular and respiratory morbidity, disability and decline of quality of life. Laboratory analyses were aimed at identifying the following factors: (i) Genetic markers related to pro-and anti-inflammatory cytokine- codifying genes. (ii) Oxidative stress-involved molecules, and inflammation-involved genes, and more in general genes involved in the brittleness (ApoE). (iii) Appraising the degree of interaction with non-genetic factors, like measurable immunological markers in the peripheral blood, markers of reactions to oxidative stress, evaluation of metabolic parameters. Moreover, old population is expected to answer the questionnaires for evaluation of the dietary habits, physical activity, self-sufficiency, cognitive ability, motor coordination, perceived stress and social relationships.
The implementation of innovations in the care sector that have been proven effective is not always easy. The implementation of innovative care programs frequently requires adaptive implementation, modified to suit local and regional circumstances. So far there has been very little research into the strategies and factors that facilitate or impede adaptive implementation processes. In the context of a study of the conditions for successful nationwide implementation of meeting centers for people with dementia and their carers, we developed a theoretical model to trace facilitators and barriers in adaptive implementation. We proceeded on the basis of a literature study, previous experiences with setting up meeting centers, and consulting with experts. The theoretical model we constructed distinguishes different phases of implementation, and describes activities and factors that can influence implementation on the micro-, meso- and macro-level for each phase. In addition,the model distinguishes characteristics of the innovation and other preconditions that may facilitate or impede implementation during the entire process. If the model is satisfactory for the study of the implementation of meeting centers, perhaps it can also be used to study other types of care innovations that would benefit from adaptive implementation.
Hyperhomocysteinemia may be a risk factor for cognitive impairment. Methylenetetrahydrofolate reductase (MTHFR) is a key enzyme in homocysteine (Hcy) metabolism. Both the MTHFR 677C-->T and the 1298A-->C polymorphisms are associated with mild hyperhomocysteinemia, particularly in conditions of low folate status. The prevalence of these MTHFR polymorphisms and their relationships with plasma total Hcy (tHcy), serum folate and cognitive function was evaluated in 194 elderly Italian individuals: 122 healthy controls (73.8 +/- 7.1 years of age), 24 cognitively-impaired-not-demented individuals (78.6 +/- 9.3 years), and 48 subjects with Alzheimer dementia (AD = 26), vascular dementia (VD = 22; 85.5 +/- 7.0, years). Twenty-one percent of all subjects were homozygous for 677C-->T and 7 % for 1298A-->C polymorphism. No significant relationship was found between MTHFR polymorphisms and age, cognitive status and type of dementia. Plasma tHcy did not differ significantly by MTHFR genotypes, but, subjects of all genotypes with low serum folate (<12 nmole/l) had higher plasma tHcy (p < 0.001), than subjects with high serum folate (>= 12 nmole/l). The study suggests that 677C-->T and 1298A-->C polymorphisms are common in the Northern Italian population, but do not significantly affect plasma tHcy levels of elderly-individuals, even under conditions of low folate status. The lack of association of age and cognitive function with MTHFR genotypes argues against a negative selection for these polymorphisms.
This study was performed to assess whether patients with Parkinson's disease (PD) develop cognitive and psychiatric impairments more frequently during therapy with continuous subcutaneous apomorphine infusion (CAI) compared to the standard oral treatment. Thirty consecutive PD patients with severe motor fluctuations were included. Of them, 12 patients received the CAI treatment, while the remaining 18 continued the treatment with oral dopaminergic drugs. The two groups were evaluated with neuropsychological, psychiatric and motor tests at baseline and after two years. The off-awake daily duration and the levodopa dosage were significantly reduced in the patients infused with apomorphine. In comparison with the baseline evaluation, the neuropsychiatric assessment did not change in either of groups at the follow-up, except for a significant improvement of mood in the CAI treated group.
A study has been carried out in our geriatric rehabilitation wards, to know better the role of cognitive dysfunction in treatment outcome and processing, mainly functional recovery and comorbidity. We analyzed 478 frail inpatients, 2/3 of them were females, aged 78.7 + 9.2 years, consecutively admitted to the unit. Assessment of cognitive function was performed by the mini mental state examination (MMSE), of functional status by Barthel index (BI), of co-morbidity by cumulative illness rating scale (CIRS) both at the admission and discharge for each patient, together with the usual clinical parameters and social outcome. More than one people in three lived alone and showed some communication problems; one in seven needed modifications in food preparation or nutritional system;more than one in five had pressure sore >/= 2 (EPUAP = European Pressure Ulcers Advisory Panel classification). The mean (+/- SD) levels of the admitted were: MMSE = 20 +/- 7.2; BI total score = 45.5 +/- 28.9; CIRS class = 4 +/- 2, CIRS severity score = 1.9 +/- 0.4. Of the patients, 74.5% were discharged to home. Mean functional gain was 20 points at BI: 65.6 +/-30.7; MMSE improved to 21.6 +/- 7.1 (p = 0.00005 for both comparisons, by Wilcoxon test).MMSE was positively correlated to BI (r = 0.6, p = 0.0005) and negatively correlated (p =0.0005) to CIRS comorbidity (r = -0.33) and severity (r = -0.26), and to age (r = -0.38, p =0.0005) both at admission and at discharge. MMSE at admission was correlated neither to functional gain, nor to improvement of clinical indicators, nor to measures of functional and clinical efficiency. MMSE at discharge showed similar results. In a stepwise multiple correlation analysis, taking the gain in BI as the dependent variable, while BI, serum albumin level, MMSE, CIRS severity and comorbidity indexes at admission as independent variables, MMSE together with BI admission total score and CIRS severity index retained a strong association with functional gain, whilst admission serum albumin levels and CIRSindex lost it. Consistently with some literary data, we showed the actual possibility of functional and clinical gains for people cared in a geriatric rehabilitation ward, all through a wide range of MMSE score, including subnormal scores. Poor cognitive status bears heavily on frailty, but does not hamper the outcomes of genuine rehabilitative efforts in geriatrics.
Clinical trials have demonstrated the efficacy of cholinesterase inhibitors (ChEI) in improving cognitive status and disability in subjects with mild to moderate Alzheimer's disease (AD). However, little is known about the effectiveness of ChEI in clinical practice, and no large clinical trials comparing different ChEI are available at present. Aim of this study was to evaluate safety and effectiveness of ChEI in a sample of elderly outpatients diagnosed with mild to moderate AD. We selected 407 subjects for ChEI treatment (donepezil, rivastigmine or galantamine). Their cognitive function was evaluated by means of the mini mental state examination (MMSE), and the global functional status was estimated by using the activities of daily living (ADL) and the instrumental activities of daily living (IADL) scales at baseline (T-0), then after 1 (T-1), 3 (T-2) and 9 months (T-3), respectively. T-3 follow-up was completed by 212 subjects. The patients were considered as responders (R), if the MMSE score at T-2 was unchanged or improved, if compared to that of To. In 35 patients (8.6%) treatment was withdrawn because of mostly gastrointestinal adverse events. Compared to the other drugs, donepezil was associated with a lower incidence of withdrawals due to adverse events. Subjects who completed T-3 follow-up (age 78 +/- 6 years, MMSE scores 18.8 +/- 3.9) showed an increase at T-2 of 0.7 +/- 2.7 (p = 0.001) and a decrease at T-3 of -0.6 +/- 3.4 (p = 0.008) in the MMSE scores, as compared to T-0. The ADL and IADL scores did not show significant changes at T-2; however, both decreased significantly at T-3. The patients R-at-T-2 showed a better cognitive and functional outcome at T-3, compared to the non-responders (NR-at-T-2), displaying values of MMSE R-at-T-2 0.4 +/- 3.1 vs. NR-at-T-2 -3.0 +/- 2.5,-p = 0.001, and ADL values of -0.3 +/- 1.2 vs. -0.7 +/- 1.3, p = 0.03, respectively. No significant difference was found in the changes of MMSE scores between donepezil and rivastigmine (galantamine was not included in the comparison due to the small number of treated subjects). In conclusion, in this sample of elderly subjects with mild to moderate AD, treated with ChEl, a small but significant decline in cognitive and functional status was observed after 9 months. Subjects who showed a good response to treatment after 3 months, had a better cognitive and functional outcome at 9 months. No significant difference in cognitive outcome was found between drugs, while donepezil was better tolerated.
An unspecific feeling of fatigue and asthenia often pushes elderly patients to require any form of help even from non medically trained people. Traditional Chinese medicine suggest that Siberian ginseng could act as safe "adaptogenic" substance. Our aim was thus to test the effect of a middle term Eleutherococcus senticosus Maxim. (Araliaceae) administration on elderly, health related quality of life (HRQOL). 20 elderly hypertensive and digitalized volunteers (age >/= 65 years) were randomized in a double -blind manner to E. senticosus dry extract 300 mg/day (n = 10) or placebo (n = 10) for 8 weeks. The short form-36 health survey version 2 (SF-36v2), a validated general health status questionnaire, was used to access HRQOL at baseline and at 4 and 8 weeks. There were no significant differences in baseline demographics and SF-36v2 scores between the groups. At each visit, controls of digitalemia and blood pressure level were carried out. After 4 weeks of therapy, higher scores in social functioning (p = 0.02) scales were observed in patients randomized to E. senticosus; these differences did not persist to the 8-week time point. No adverse event has been observed in both groups of patients. No significant difference in both blood pressure control and digitalemia was observed in both treatment groups. Subjects give E. senticosus (70%) were more likely to state that they received active therapy than subjects given placebo (20%; p < 0.05). In conclusion, E. senticosus safely improves some aspects of mental health and social functioning after 4 weeks of therapy, although these differences attenuate with continued use.
It was aimed at evaluating the clinical usefulness of the mini nutritional assessment (MNA) to identify malnutrition in elderly patients with cognitive impairment, admitted to a geriatric convalescence unit (intermediate care facility). Sixty-three patients with cognitive impairment were studied. Cognitive impairment was considered when mini mental state examination (MMSE) scores were below 21. MNA and a nutritional evaluation according to the sequential model of the American Institute of Nutrition (AIN) were performed at admission. According to the AIN criteria, malnutrition was considered, if there were abnormalities in at least one of the following parameters: albumin, cholesterol, body mass index (BMI), and branchial circumference. Based on these criteria, 27 patients (42.8%) proved to be undernourished at admission, whereas if taking the original MNA scores, 39 patients (61.9%) were undernourished, 23 (36.5%) were at risk of malnutrition, and 1 (1.5%) was normal. The analyzed population was divided in four categories (quartiles) of the MNA scores: very low (= 13.5), low (> 13.5 and = 16), intermediate (> 16 and = 18.5) and high (> 18.5). Likelihood ratios of each MNA quartile were obtained by dividing the percentage of patients in a given MNA category who were undernourished (according to AIN) by the percentage of patients in the same MNA category who were not undernourished. In the very low MNA quartile, this likelihood ratio was 2.79 and for the low MNA quartile it was 0.49. For intermediate and high MNA categories, likelihood ratios were 1.0 and 0.07 respectively. In the present study, MNA identified undernourished patients with a high clinical diagnostic impact value only, when very low scores (= 13) are obtained.
Physicians often need to be able to assess cognition in a simple way, particularly for screening of subclinical processes in aged people. This paper describes a new, quick test battery called preventive-comprehensive assessment (PCA). It consists of six various testing items (repetition of three words, back-spelling of the word "sport", problem searching ina complex picture, recall of the three words, three progressive colored matrices, clock drawing test), evaluating language, recent memory, executive function, judgment and thinking capacities. The total scores. compared to the normal performance of different age groups, allow us to distinguish between normal and pathological status. If abnormal results are recorded, we need to perform further and deeper neuropsychological investigations, in order to obtain the possibly exact diagnosis. The PCA battery is sensitive and reliable; it can be used in itself, or as a part of a more complex battery of an intense comprehensive evaluation (ICE), carried out in population screening aimed at promoting healthy and active aging.
The complexity has been viewed as an obstacle to medical research which, by necessity, depends on reduction. As a consequence, medical science often uses logical reductions in the attempt to understand the various facets of different clinical syndromes.However, such a reduction is not always possible in psychogeriatric syndromes where the clinical and biological complexity is the rule rather than the exception, and to identify correlation of signs and symptoms to a specific disease is often a difficult task. The present paper describes the complex relationships and interactions between the mood, behavior and memory. It is also suggested that the comprehension of psychogeriatric syndromes should not be based only on a separate analysis of these 3 elements (i.e., mood, behavior and memory), but on a multidimensional assessment of their reciprocal and dynamic interactions which may concur in the determination of the outcomes.
Hyperhomocysteinemia is an important risk factor for atherosclerosis and it has recently been suggested as a diagnostic marker for Alzheimer disease (AD). The present studies compared homocysteinemia in patients with AD and with vascular dementia (VD),as well as in controls. Homocysteinemia was measured in 137 probable AD patients,diagnosed by the NINCDS-ADRDA criteria, in 40 probably VD patients diagnosed by the NINDS-AIREN criteria, and in 42 control subjects. Homocysteine levels were significantly higher in AD and VD groups, than in controls, however, VD patients were significantly older than the controls. The proportion of females was higher in the AD group, while serum folate and B12 vitamin levels tended to be lower in both the AD and VD groups, compared to the controls. In order to adjust the results for these potentially interfering factors, a multivariate ANCOVA calculation was performed, where homocysteine levels were analyzed considering 2 grouping factors (gender and neurological type) and 4 covariates (age, albumin,serum folate and vitamin B12 ). This analysis confirmed that even after adjusting for the covariates, the difference between AD and VD groups and controls remain highly significant,while neither the gender itself, nor the interaction of gender and the neurological type had any significant influence on the homocysteine levels. The main finding, therefore, is a significant increase of homocysteine levels in the 2 disease groups, compared to controls.
A Geriatric Home Hospitalization Service (GHHS) has been operating in Torino at S. Giovanni Battista Hospital since 1985. GHHS allows us to perform diagnostic and therapeutic interventions, which are usually made in hospital, also at home. GHHS team includes geriatricians, nurses, physiotherapists, social workers and counselors. Between February 1999 and April 2002, the GHH Service conducted a randomized controlled trial on 109 elderly, demented patients requiring admission to the Hospital Emergency Department (ED)for acute illnesses. Objective of the study was to identify the benefits of the care in a GHHScompared to a general medical ward (GMW) in reducing behavioral disturbances in elderly patients with advanced dementia and in lowering caregiver's stress. Patients were randomly assigned to GHHS (56 patients) or to GMW (53 patients). Both groups were examined using the same protocol and were evaluated on admission and on discharge. All patients had a severe form of dementia as shown by the clinical dementia rating (CDR) scale mean value (3.7 +/- 0.9) with an important functional impairment and a relevant degree of comorbidity.The main reasons for hospitalization were infections, cerebrovascular accidents and malnutrition. Mortality of total sample was 19.3 %, without significant differences in the two settings of care. On discharge, in GHHS patients there was a significant reduction of behavioral disturbances. The use of anti-psychotic drugs was significantly lower in GHHS patients compared to the GMW group (p < 0.001). The stress of caregivers on discharge was reduced only in GHHS group and not in the control ones. In conclusion, we can say that a GHHS continuous support allows us to reduce the family caregiver's stress. When treated at home, demented patients do not have to change their environment or routine and it is possible to have a better control on behavioral disturbances.
Senescence is accompanied by an important increase in prevalence and incidence of ischemic stroke. The plasma level of fibrinogen tends to increase with age in the elderly similarly to the prevalence of stroke. The aim of our study was to evaluate the age-related increase in fibrinogen plasma level in the elderly and to assess the presence of eventual differences between normal subjects and patients with previous ischemic stroke associated with precerebral atherosclerosis. Eighty inpatients (41 males and 39 females), consecutively admitted to our Geriatric Unit, were included to this study. The patient group was formed 32 subjects (20 males and 12 females) aged 50-79 years, suffering from cerebrovascular disease with one or several previous ischemic stroke episodes, having occurred at least 1 year earlier. The control group consisted of 48 normal subjects (21 males and 27 females) aged 50-79 years. Both control and patient groups were subdivided into three subgroups, according to their age: Group 1 (50-59 years), Group 2 (60-69 years) and Group 3 (70-79 years). The statistical comparison was carried out by means of the Mann-Whithney nonparametric test. In normal controls, a mild age effect is evident because only Group 3 shows fibrinogen levels significantly higher than those of Group 1. On the contrary, in patients with ischemic stroke, an age effect is already evident between Group 2 and Group 1; of course, also the comparison between patient Group 3 and Group 1 shows a statistically significant difference. Moreover, the levels of fibrinogen were significantly increased in patient Group 2 and 3 when compared to those of their respective age-matched controls. Our data are in agreement with those already available in the literature and demonstrate that fibrinogen in normal aging changes with age and shows a 19 % increase between age Group 1 and Group 3. Patients with ischemic stroke show an earlier and more evident age-related increase in fibrinogen than normal controls. Even if it is not possible to know, if the increase in fibrinogen is a consequence or not of the ischemic stroke, we can affirm that certainly the increased levels of fibrinogen should be considered as an important risk factor in the elderly for cerebrovascular disease and deserve treatment.
