Societá

Attivitá SIGG

Giornale di Gerontologia

Numero 5, Ottobre 2006 - Volume LIV - Supplemento

Introduzione


Bruno Dallapiccola
Direttore Scientifico Casa Sollievo della Sofferenza, IRCCS CSS-Mendel, Roma
Franco Rengo
Presidente FIRI, Fondazione Italiana per la Ricerca sull´Invecchiamento Universitá Federico II, Napoli
Alberto Pilotto
Direttore U.O.C di Geriatria Casa Sollievo della Sofferenza, IRCCS San Giovanni Rotondo

G GERONTOL 2006;54(Suppl 2):1

Gli Incontri di Geriatria 2006 a Casa Sollievo della Sofferenza di San Giovanni Rotondo sono stati inseriti quest´anno nell´ambito delle manifestazioni per il 50° Anniversario della Fondazione dell´Ospedale voluto da Padre Pio da Pietrelcina. Per questo, forse, gli Incontri di Geriatria 2006 hanno avuto un sapore speciale, testimoniato da una intensitá e ricchezza di contenuti particolarmente elevati. La rivoluzione demografica che ha investito il mondo occidentale negli ultimi 50 anni ha colto impreparati la societá, la politica e tutto il mondo scientifico che troppo tardi si é accorto che i malati sono soprattutto anziani e che le loro peculiaritá biologiche, psicologiche e sociali giocano un ruolo determinante l´evoluzione delle malattie e delle disabilitá dell´anziano.
La Geriatria é la disciplina che cerca di colmare i ″vuoti″ culturali che circondano l´anziano sia offrendo idee nell´ambito della ricerca di base sia fornendo soluzioni cliniche che siano efficaci. Al riguardo, la diffusione sempre piú ampia della Valutazione Multidimensionale e la caratterizzazione biologica e clinica dell´Anziano Fragile potranno permettere di trovare risposte piú adeguate al paziente anziano.
In un´epoca di razionalizzazione di risorse sanitarie e assistenziali il rischio di discriminare il malato anziano é pericolosamente concreto. Le scelte gestionali e cliniche per la persona anziana debbono oggi tener conto delle evidenze scientifiche come anche delle considerazioni etiche senza che criteri meramente economici possano influire su principi fondamentali come dignitá della persona, qualitá di vita, diritto alla diagnosi, cura e assistenza in tutte le etá della vita.
Una maggiore attenzione alla prevenzione, alla creativitá e alla spiritualitá in etá anziana acquista il grande significato di valorizzazione del potenziale biologico, mentale, etico e spirituale che l´anziano possiede forse in quantitá superiore rispetto a chi anziano non é ancora diventato.
L´ampio interesse suscitato dalle relazioni ci ha spinto anche quest´anno a raccogliere i testi in un apposito Supplemento del Giornale di Gerontologia, ritenendo che i contenuti presentati non dovessero circolare soltanto nel ristretto pubblico che ha partecipato alle tre giornate ma meritassero di raggiungere tutti i soci della Societá Italiana di Gerontologia e Geriatria.
Ringraziamo di cuore tutti i relatori che con tanta competenza e generositá hanno saputo portare agli Incontri di Geriatria 2006 le loro esperienze cliniche e di ricerca. Ci auguriamo sinceramente che la lettura delle pagine che seguono possa fornire spunti di arricchimento e approfondimento professionale a tutti quei colleghi e amici che, come noi, hanno voluto dedicare la propria vita professionale al mondo degli anziani.

Copertina

Sommario

LA PREVENZIONE IN GERIATRIA

Invecchiamento della popolazione e le nuove
aree di rischio in sanitá


S. MAGGI, F. LIMONGI, P. SIVIERO, D. BIANCHI, G. CREPALDI
CNR, Sezione Invecchiamento di Padova

G GERONTOL 2006;54(Suppl 2):2-6

Research studies in Geriatrics have recently led to the identification of new modifiable risk factors for morbidity, disability and death in older individuals. In this manuscript we will discuss the role of depressive symptoms, a frequent and often under-treated condition, in determining new cardiovascular events. A second area of risk is identified in the profile of care for hip fractures. Hip fractures can lead to disability and death and can worsen significantly the quality of life of older patients. Specific guidelines for their hospital treatment are available, but the high variability across centers in the rate of surgical interventions and in the timing of surgery demonstrate the lack of standardized care. A hip fracture registry would help in monitoring the profile of care and its outcome and would allow specific suggestions for the standardization of the hospital treatment.

Key words: Epidemiology - Depression - Hip fracture - Profile of care

Approcci innovativi per la prevenzione del rischio vascolare nell´anziano

A. CAPURSO, C. CAPURSO*, V. SOLFRIZZI, F. PANZA
Cattedra di Geriatria, Centro per lo Studio del Metabolismo Lipoproteico e dell´Aterosclerosi, Universitá
di Bari, Bari, Italy; * Cattedra di Geriatria, Universitá di Foggia, Foggia, Italy

G GERONTOL 2006;54(Suppl 2):7-11

Hypercholesterolemia has frequently been considered a uncertain risk factor in old people due to prospective studies who failed to demonstrate statistically significant association between elevated levels of total cholesterol and all cause mortality. Recent large trials on statins have clearly demonstrate the significant reduction of coronary (CHD) and cerebrovascular (CVD) acute events also in patients over 70 years, leading to the conclusion that pharmacological prevention of vascular events with statins is effective in old people as it is in the young people. If we consider that with aging the vascular risk profile modifies from prevalently cardiovascular to prevalently cerebrovascular, the most beneficial effects of statin in elderly may be considered the significant reduction of stroke, which appears to be of the same size as CHD risk reduction. Moreover, considering that antihypertensive treatment reduces stroke by 35-40% and CHD by 14-20%, the addition of a statin to antihypertensive treatment in ASCOTT-LLA trial has demonstrated to promote a greater reduction in CHD and CVD acute rate events, which appears to be additional to the beneficial effects obtained with the usual antihypertensive treatment.

Key words: Hypercholesterolemia - Elderly - Cardiovascular risk - Cerebrovascular risk - Statins

La prevenzione delle complicanze trombotiche dell´aterosclerosi nell´anziano

M.N.D. DI MINNO, A. TUFANO, G. DI MINNO*
Cattedre di Medicina Interna e di Reumatologia, Dipartimento di Medicina Clinica e Sperimentale, Policlinico ″Federico II, Napoli; * IRCCS ″Casa Sollievo della Sofferenza″, S. Giovanni Rotondo, Foggia

G GERONTOL 2006;54(Suppl 2):12-17

Stroke and myocardial infarction are major complications of atherosclerosis (atherotrombosis). The risk of such complications increases with age, subjects over sixty years of age contributing to over 60% of mortality for myocardial infarction. The increased risk of thrombotic complications of atherosclerosis correlates with an high incidence, with age, of obesity, hyper-coagulability, diabetes mellitus, hypertension, hyperlipidemias, low HDL-cholesterol.

In parallel, older patients have a higher than normal risk of cerebral bleeding, mostly in those with severe hypertension, psychiatric disorders, traumas or a history of stroke. In view of this, antithrombotic strategies in older individuals require a careful evaluation of the patient, and tailored strategies as to dosing and scheduling of the drug(s).

Antiplatelet treatment: aspirin at dosage of 75-100 mg/d, is the strategy of choice as to secondary prevention of stroke and myocardial infarction in the elderly, common contraindications to this treatment being aspirin allergy, severe hypertension and peptic ulcer. Ticlopidine is an appropriate alternative to aspirin. However, it requires a repeated blood counts (risk of neutropenia), mostly in the first weeks of treatment. Clopidogrel is a valuable strategy in the elderly, because of its efficacy and safety.

Anticoagulant treatment (heparin or warfarin) should be used with caution in the elderly, because of the inherent side effects (tendency to bleed). However warfarin is a major strategy to prevent stroke in high risk individuals (e.g. those with non-rheumatic atrial fibrillation), in individuals > 65 years of age warfarin being better and as safe as aspirin.

Key words: Atherothrombosis - Stroke - Myocardial infarction - Aging - Aspirin - Ticlopidine - Clopidogrel - Oral anticoagulants

I DISTURBI COGNITIVI DELLANZIANO

La depressione in etá avanzata: dalla epidemiologia alla clinica

A. CHERUBINI
Istituto di Gerontologia e Geriatria, Universitá di Perugia

G GERONTOL 2006;54(Suppl 2):18-24

Depression is a common and serious health problem in the elderly, but it is often under-diagnosed and under-treated. Depression is frequently coexistent with other medical illnesses, with a bidirectional association, being a risk factor for several physical illnesses and also a consequence of many diseases. In older patients it is often expressed by somatic complaints more than by emotional symptoms. Depression decreases the quality of life and increases disability and the risk of mortality, also due to suicide.

Key words: Depression - Older subjects - Disability - Somatic complaints

La terapia della depressione tra evidenze e complicanze

R. ROZZINI
Dipartimento di Medicina Interna e Geriatria, Ospedale Poliambulanza, Brescia e Gruppo di Ricerca Geriatrica

G GERONTOL 2006;54(Suppl 2):25-30

The etiology of depression, the mood disorder most frequently studied, is far from ideally understood. Many cases of depression are triggered by stressful life events, yet not everyone becomes depressed under such circumstances. The intensity and duration of these events, as well as each individual´s genetic endowment, coping skills and reaction, and social support network contribute to the likelihood of depression. That is why depression and many other mental disorders are broadly described as the product of a complex interaction between biological and psychosocial factors. The relative importance of biological and psychosocial factors may vary across individuals and across different types of depression. Surveys consistently document that a majority of individuals with depression receive no specific form of treatment. Undertreatment of mood disorders stems from many factors, including societal stigma, financial barriers to treatment, underrecognition by health care providers, and underappreciation by consumers of the potential benefits of treatment.
The paper describes the background of an efficacious treatment and the ways to get elderly people into treatment.

Key words: Depression - Elderly patients - Therapy

La pre-demenza: diagnosi e prognosi del mild cognitive impairment

F. PANZA, A. D´INTRONO, A.M. COLACICCO, C. CAPURSO*, A. PILOTTO**, G. GAGLIARDI, P.L. SCAPICCHIO***, E. SCAFATO****, A. CAPURSO, V. SOLFRIZZI
Cattedra di Geriatria, Centro per lo Studio dell´Invecchiamento Cerebrale, Memory Unit, Universitá di Bari, Bari, Italy; * Cattedra di Geriatria, Universitá di Foggia, Foggia, Italy; ** Dipartimento di Geriatria, ″Casa Sollievo della Sofferenza″, IRCCS, San Giovanni Rotondo, Foggia, Italy; *** Universitá Cattolica del Sacro Cuore, Roma, Italy; **** Istituto Superiore di Sanitá, Roma, Italy

G GERONTOL 2006;54(Suppl 2):31-43

Different diagnostic criteria and terms have been proposed to describe clinical predementia syndromes in the elderly, although the epidemiology of these syndromes has not been thoroughly investigated. Prevalence and incidence of different predementia syndromes vary as a result of different diagnostic criteria, as well as different sampling, and assessment procedures. Age, education level, and gender are not consistently related to the prevalence rates of predementia syndrome. As for dementia, the incidence rates of predementia syndrome appear to increase with aging and are higher in subjects with low education. Particular interest in Mild Cognitive Impairment arises from the fact that Mild Cognitive Impairment is thought to be a prodromal phase and therefore highly predictive of subsequent Alzheimer´s disease. Several studies have suggested that most of the patients who met the Mild Cognitive Impairment criteria will progress to Alzheimer´s disease, but rates of conversion to Alzheimer´s disease and dementia vary widely among studies, partly because of the characteristics of the population studied and the length of follow-up. Furthermore, recent findings suggest that in population-based studies the Mild Cognitive Impairment classification is unstable, in contrast with clinic-based studies where progression is more uniform.

Key words: Dementia - Mild cognitive impairment - Aging-associated cognitive decline - MCI - AACD - ARCD - AAMI - Alzheimer´s disease - Vascular dementia

La demenza in fase avanzata: problemi di diagnosi, terapia o di assistenza?

A. CESTER, M. FORMILAN*, F. BUSONERA*, P. ALBANESE*, A. TESSARI*, E. VITALE*, C. FAGHERAZZI*, S. PERUZZA*, C. BERGAMIN*
Direttore del Dipartimento di Geriatria e Riabilitazione dell´Azienda ULSS 13 di Mirano (VE), sede di Dolo; * UVA ed U.O. del Dipartimento di Geriatria e Riabilitazione dell´Azienda ULSS 13 di Mirano (VE), sedi di Dolo, Mirano e Noale

G GERONTOL 2006;54(Suppl 2):44-47

Advanced phases of dementia are perhaps the more critical area of interest and the less studied in the scientific and academic word and the scientific search in comparison to the initial phases of illness or to the diagnosis clinical pre that seem today the mostly interesting. These patients are orphan of therapeutic and relief resources and they burden on the care givers with the whole burden of mourning and increasing relief necessity that are typical of this phase of illness. It will need to devote time, financings and greater studies of close examination to the study of these phases and attempting to give a concrete support to the care givers in terms of ″true″ taken in assistencial burden.

Key words: Elderly - Advanced dementia

LE NUOVE FRONTIERE DELLA RICERCA IN GERIATRIA

La genetica in geriatria: da fattore di rischio alla farmacogenetica

B. DALLAPICCOLA* **, D. SERIPA***, A. PILOTTO*** ****
* Istituto ″CSS-Mendel″, Roma; ** Dipartimento di Ricerca, IRCCS ″Casa Sollievo della Sofferenza″, San Giovanni Rotondo (FG); *** Laboratorio di Gerontologia e Geriatria, Dipartimento di Ricerca, IRCCS ″Casa Sollievo della Sofferenza″, San Giovanni Rotondo (FG); **** Unitá Operativa di Geriatria, Dipartimento di Scienze Mediche, IRCCS ″Casa Sollievo della Sofferenza″, San Giovanni Rotondo (FG)

G GERONTOL 2006;54(Suppl 2):48-53

Aging is a complex systemic process caused by multiple genetic factors interacting with enviroment and lifestyle. Mendelian genetics offers several important examples for approaching the decodification and quantification of this complex process, to clearly identify the underlying genetic component, and to understand the physiological process of aging. This effort also provides some insight into pharmacogenetics, to discover the genetic component of individual response and adverse reaction to drugs.

Key words: Genetics - Pharmacogenetics - Risk factors - Aging

L´arte della longevitá: contrastare l´invecchiamento per combattere la fragilitá

E. BERGAMINI
Direttore del Centro di Ricerca di Biologia e Patologia dell´Invecchiamento dell´Universitá di Pisa, Pisa

G GERONTOL 2006;54(Suppl 2):54-58

Aging denotes deteriorative changes, during the adult period of life, which underlie an increasing vulnerability to challenges, thereby decreasing the ability of the organism to survive. Thanks to economic progress and achievements in geriatric medecine, in the last century, human lifespan could be extended dramatically without any change in the aging rate. Therefore, success had a much smaller effect on healthspan and increased prevalence of frailty in older population. Discovery of biomarkers of human aging and better knowledge of the mechanism of the antiaging action of caloric restriction may open the way to early detection of pathologic aging and prevention, in order to increase both life- and health-span and curb disability and frailty.

Key words: Aging - Frailty - Anti-aging intervention - Anti-aging medecine

Valutazione Multidimensionale e prevenzione in etá geriatrica

A. PILOTTO, P. D´AMBROSIO, C. SCARCELLI, L. CASCAVILLA, V. NIRO, M.G. LONGO, F. PARIS, D. SERIPA, G. PLACENTINO, M. CORRITORE, M. FRANCESCHI
Unitá Operativa Geriatria, Dipartimento di Scienze Mediche, Laboratorio di Gerontologia e Geriatria, Dipartimento di Ricerca, ″Casa Sollievo della Sofferenza″, IRCCS, San Giovanni Rotondo, (FG)

G GERONTOL 2006;54(Suppl 2):59-64

The Comprehensive Geriatric Assesssment (CGA) is the first-choice tool for evaluating functional, cognitive, social and clinical aspects of elderly subjects. The main characteristics of CGA are as follows: 1) to be performed by a multidisciplinary team; 2) to be able to evaluate the functional and clinical aspects of the subject; 3) to plan a tailored assistance and health program for the subject; 4) to carry out a follow-up program of the elderly subject.
Several studies documented an high efficacy of CGA in reducing re-hospitalization, institutionalization and short-term mortality rates; moreover, CGA is useful in improving functional and cognitive status and in prevention of malnutrition. CGA is more useful when performed in combination between hospitalward and extra-hospital services. Heterogeneity of methods in performing CGA, however, is still present and does not permit a complete evaluation of its useful in some settings of elderly subjects. Very recently it has been reported the usefulness of CGA in constructing a prognostic index of mortality useful for clinical and research purposes.

Key words: Comprehensive geriatric assessment - Frail elderly

QUALE BIOETICA PER LA PERSONA ANZIANA?

La dignitá della persona umana in ogni fase della sua esistenza

E. SGRECCIA
Presidente della Pontificia Accademia per la Vita e della Federazione Internazionale dei Centri ed Istituti di Bioetica di Ispirazione Personalistica, Roma

G GERONTOL 2006;54(Suppl 2):65-77

The recent crisis of the anthropology in the occidental culture, influenced by the secularization, produces the loss of the sense of man, of his ontological value and his dignity, and leads to the reductionism.
This crisis is overall characterised by the exaltation of individual rationality and moral autonomy, eradicated from the transcendent Being, by the freedom interpreted both as internal root and as end of own acts, and finally by the identification of quality of life with the capability to feel pleasure and win pains. In this context the old age, with its rich store of maturity and wisdom, is considered an unproductive and useless period of the human existence; so the elderly is more and more marginalized; he/she is not considered a ″subject of rights″ because he/she wouldn´t have autonomy and capacity of self-determination.
On the contrary, the ontologically founded personalism, through the identification between human being and human person, recognizes the value and the dignity of man from conception to death. In particular the personalism asserts an ontological vision of the corporeity, that means more than biology: it has moral meaning. So, about medical and human care to the dying elderly, the personalist bioethics asserts: a) the refusal of euthanasia and overtreatment; b) the evaluation of proportionality of treatments for the patient; c) the right and proper continuation of ordinary care (nutrition and hydration, corporal hygienic, dressings, cleansing of ulcers); d) the promotion of a care that responds to patient´s needs, clinic of course but also moral, psychological and spiritual.

Key words: Human person - Dignity - Old age - Ontologically founded personalism

La gestione delle risorse in medicina tra etica e discriminazioni

D. SACCHINI
Istituto di Bioetica, Facoltá di Medicina e Chirurgia ″Agostino Gemelli″, Universitá Cattolica del Sacro Cuore, Roma

G GERONTOL 2006;54(Suppl 2):78-84

The article deals with the delicate matter of the resources management in geriatric healthcare, between ethics and discriminations, beginning from the assumption that seniority is a complex universe, healthcare aspects enclosed. Then, a synthetic review of the demographic and epidemiological data around the elderly is showed.
Secondly, the different criteria and tools of the economic science used for establishing the allocative priorities in health are critically analysed: the targets of health, the burden of disease, the QALYs; the avoidable death, and the pertinence. Finally, the ethical value of the management of the healthcare resources in geriatrics is argued, trying to settle two fundamental issues: the pertinence of the ethics/economics relationship and the choice of the priority-value on the scenario of the ethical perspective assumed by decision-maker.

Key words: Economics - Healthcare resources allocation - Ethics - Geriatrics

La gestione del malato terminale: ″cure normali″, accanimento terapeutico, eutanasia

G. CERA
Chirurgo d´urgenza, Unitá Operativa di Pronto Soccorso, IRCCS ″Casa Sollievo della Sofferenza″, San Giovanni Rotondo (FG), Dottorando di ricerca in Bioetica, Universitá Cattolica del Sacro Cuore, Roma

G GERONTOL 2006;54(Suppl 2):85-91

Up to now, much more then the past, the approach to terminal patients imposes a multidisciplinary reflection to stimulate a continuous discussion between more ambits of the knowledge as medicine, ethics, anthropology, philosophy, law, deontology, psychology and faith.
In order to establish an ethical approach to terminal patients, it becomes necessary and urgent a careful distinction between normal care (palliative care), over-treatment and euthanasia, terms often missunderstood.
Nutrition and hydration can´t be considered medical therapy, even if given artificially. They should be considered normal care: in spite of this, they can be interrupted only in the case of no assimilation by the organism; their undue suspension must be interpreted as euthanasia.
In modern society, the deeper meaning of calling for euthanasia together with the over-treatment practice´s, can be located in: the lost of a just anthropology; in the lost of conceiving human being; in the lack of the respect due to human dignity in any human condition, including physical suffering; loosing the meaning of human life; lacking the meaning of suffering and death. Therefore, a true bioethics on the terminal life question´s needs an anthropology based on the ontological and global truth of the man.
Ethics too, which by definition tends toward man´s good, will find the answer solely in the truth of man (verum et bonum sunt idem). This ″ethics of the truth″, opposed to the ″ethics without truth″ - coming from some relativistic models - belongs to the just reason, to the just anthropology, to the right consciousness. In this perspective, human life must be considered always an undisposable good, independently from the quality of life, or the autonomy or the capacity to mean and wish. Human suffering calls for love and social solidarity: this is not achieved by suppressing life prematurely.

Key words: Terminality - Normal care - Over-treatment - Euthanasia - Ethics - Bioethics

La moderna geriatria tra accanimento e astensionismo. Il paziente affetto da demenza

M. TRABUCCHI
Universitá ″Tor Vergata″ di Roma e Gruppo di Ricerca Geriatrica, Brescia

G GERONTOL 2006;54(Suppl 2):92-96

We discuss the most important problems related with the last part of the life of persons affected by advanced dementia. The article proposes peculiar attitudes by physicians to reduce the suffering of patients, without modifying the natural history of each individual.

Key words: Dementia - Aggressive therapy - Withdrowing care

Spiritualitá e salute dell´anziano

M. PETRINI
Centro di Promozione e Sviluppo dell´Assistenza Geriatrica, Facoltá di Medicina e Chirurgia ″A.Gemelli″, Universitá Cattolica del Sacro Cuore; Istituto Internazionale di Teologia Pastorale Sanitaria ″Camillianum″, Roma

G GERONTOL 2006;54(Suppl 2):97-100

More and more scientific publications and journals are dealing with the theme about taking into consideration the spiritual dimension of the patient in medical and health-care practice. Spirituality is constitutive of a person which, and in old age, it assumes particular importance; hence, the well-being of the whole person cannot but derive from a correct interrelationship among the biophysical, psychological and spiritual aspects. This is why the spirituality of the elderly is considered a health-care concern in geriatric institutions.

Key words: Aging - Spirituality - Health care