Societá

Attivitá SIGG

Giornale di Gerontologia

Numero 2, Aprile 2008 - Volume LVI

Sommario

Editoriale

La Geriatria nelle cure primarie

C. Mussi, G. Salvioli
Cattedra di Geriatria e Gerontologia, Centro di Valutazione e Ricerca Gerontologia, Universitá di Modena e Reggio Emilia

G Gerontol 2008;56:51-55

Parole chiave: Anziani - Geriatria - Malattie croniche - Istruttore del benessere - Gestione - Cure primarie
Key words: Older - Geriatrics - Chronic diseases - Health coach - Management - Primary care

La Geriatria si dedica alla cura, alla prevenzione e alla riabilitazione delle malattie acute e croniche tipiche della popolazione anziana, preoccupandosi non solo delle procedure di gestione, ma anche della ricerca e della didattica relative a questo crescente settore della medicina e della sanitá. L´approccio ai problemi segue ancora le classiche procedure della medicina d´attesa, c´é attivazione solo quando si manifestano i segni, i sintomi e le conseguenze spesso disabilitanti. La disciplina Geriatria e Gerontologia ha proposto una precisa definizione funzionale di fragilitá; questa é stata poi trasferita alla storia delle malattie, non enfatizzando cosí la necessitá della prevenzione precoce, basata sulle modificazioni prestazionali provocate dall´invecchiamento. La metodologia specifica della Geriatria é la valutazione multidimensionale geriatrica, spesso oggetto di interesse prevalentemente retorico nonostante la sua utilizzazione sia proposta persino nella fase acuta delle malattie e al pronto soccorso; essa consente di realizzare la continuitá delle cure e dell´assistenza per gestire efficacemente i problemi della long-term care.

Articoli daggiornamento

Terapia antiperglicemizzante nel diabete dell´anziano: ruolo degli inbitori del DDP-4

M.R. Rizzo, M. Barbieri, R. Marfella, G. Paolisso
Dipartimento di Geriatria e Malattie Del Metabolismo, Seconda Universitá di Napoli

G Gerontol 2008;56:96-102

Parole chiave: Diabete mellito - Etá geriatrica - Fisiopatologia del compenso metabolico - Linee Guida
Key words: Diabetes mellitus - Elderly - Physiopatology - Guidelines

Cenni epidemiologici: la dimensione del problema
É ormai ben dimostrato che nei paesi occidentali l´avanzare dell´etá si associa ad un incremento della prevalenza e dell´incidenza del diabete mellito. Pur tuttavia esistono sostanziali differenze in rapporto alle razze ed alle nazioni. Per esempio negli ultrasessantacinquenni degli usa vi é una prevalenza del diabete di tipo ii di circa del 16% nella razza Caucasica mentre la prevalenza sale fino al 45-50% se, per la stessa fascia di etá, sono invece considerati i Native Americans quali per esempio gli indiani Pima. in Europa, il paese con la piú alta prevalenza di diabete nella popolazione anziana, é la Finlandia dove si arriva al 35% degli ultrasessantacinquenni affetti da tale patologia. in italia invece la percentuale é ancora contenuta intorno al 6-8% ma tale stima tenderá sicuramente a crescere in considerazione del crescente numero di soggetti che sono affetti da diabete mellito nell´ambito degli adulti. a causa di tale incremento vi é stato un consequenziale incremento dei soggetti anziani affetti da diabete mellito di tipo 2 specie nei Paesi occidentali.

Articoli originali

Cinque anni di Riabilitazione Geriatrica 2002-2006: gli outcome della riabilitazione

E. Cunietti, R. Bagnoli, A. Bracchi, A. Maestri, P. Bernocchi*, P. Esposito**
U.O. Riabilitazione Generale E Geriatrica;
* U.O. Riabilitazione Specialistica 2;
** Ufficio Qualitá, Azienda Ospedaliera Della Provincia Di Lodi

G Gerontol 2008;56:56-66

Objective: To describe changes among diseases and disabilities, to investigate in what way clinical and functional features affected rehabilitation outcomes. Methods: The study involved 1015 pts aged = 65: 73% women (median age 81), and 27% men: (median age 80). The outcomes measured were: length of stay, recovery, efficiency, functional gain (recovery = 30%), walking recovery, reduction of severe functional dependence. Pts were divided into: HF, proximal femur fractures (hip) surgically treated, n = 327; Stroke: n = 111; Medical Illnesses: n = 368; Orthopaedic Illnesses: orthopaedic diagnoses except HF, n = 103; Neurological Illnesses (Neuro): neurological diagnoses except Stroke n = 106. ″Clinically Complex″ pts were identified by Cumulative Illness Rating Scale comorbidity = 3; ″Cognitive Impairment″ by Short Portable Mental Status Questionnaire > 4; ″Malnutrition″ by Albumin < 35 g/L and ″Anaemia″ according to WHO criteria.

Results: Along 5 years we observed an increase of: length of stay (+ 33%), Cumulative Illness Rating Scale severity (+ 14%), Cumulative Illness Rating Scale comorbidity (+ 43%), BI at admission (+ 10%) and Med Illnesses (11% in 2002, 37% in 2006). Med Illnesses showed the best results as regards: Recovery, Walking Recovery, Functional gain and reduction of severe functional dependence; Orthop the best Efficiency; Neuro the shortest length of stay. Among HF, Clinically Complex pts showed outcomes significantly lower vs. pts with low comorbidity, and Pressure ulcers induced significantly lower outcomes and higher length of stay vs. pts uninjured. Among Stroke, pts malnourished had outcomes significantly lower then well nourished. Among Med Illnesses, Cognitive Impairment pts had significantly lower outcomes in comparison to intact ones, and pts with Pressure ulcers had outcomes significantly lower and longer length of stay in comparison to uninjured. In the overall series, pts with intercurrent infections had length of stay significantly longer (+ 13 d; + 30%) and outcomes significantly lower.

Conclusions: The need of Geriatric Rehabilitation among pts suffering from medical illnesses is growing, and comorbidity on the whole too. Functional, and especially clinical features at admission heavily influence the outcomes of rehabilitation.

Key words: Comorbidity - Cognition - Malnutrition - Pressure Ulcer

Fattori di rischio vascolare e demenza.
Dati dal ″Faenza Project″


C. Forlani, D. De Ronchi, B. Ferrari, E. Dalmonte*, A.R. Atti
Istituto Di Psichiatria ″P. Ottonello″, Universitá Di Bologna;
* Unitá Operativa Di Geriatria, Presidio Ospedaliero Di Faenza, Ausl Di Ravenna

G Gerontol 2008;56:67-76

Objectives: To establish whether hypertension, diabetes, dyslipidemia, overweight and peripheral atherosclerosis were related to dementia in an elderly Italian population.
Methods: The ″Faenza Project″ is a population-based study on 7930 subjects (61-107 years) who were clinically evaluated for dementia (DSM-III-R) and presence of vascular factors. Logistic regression analyses were used to estimate Odds Ratios and 95% confidence intervals in models adjusted by socio-demographic and clinical factors. Based on positive or negative associations between each factor and dementia, different clusters of factors were created (vascular profiles 1 and 2) in order to evaluate possible cumulative effects.

Results: 513 subjects (6.5%) were diagnosed as demented. Hypertension and dyslipidemia were negatively associated with dementia. The positive association between peripheral atherosclerosis and dementia was confounded by stroke. An increasing number of factors of vascular profile 1 (hypertension, dyslipidemia, overweight, negatively related to dementia) was associated with a decreasing probability to be affected by dementia. Subjects with diabetes and peripheral atherosclerosis (vascular profile 2: factors positively associated with dementia) had an increased probability to be demented.

Conclusions: The study about correlations between clusters of vascular factors and dementia is relevant for epidemiological and clinical implications.

Key words: Hypertension - Diabetes - Dyslipidemia - Overweight - Peripheral atherosclerosis - Dementia - Elderly - Epidemiology

La malattia di La Peyronie negli anziani: aspetti clinici e psicologici in uno studio su 30 pazienti

S. Iurassich, S. Goione*
Seconda Universitá di Napoli, Facoltá di Medicina e Chirurgia, Policlinico, Servizio Speciale di Terapia Fisica Dermatologica;
* Universitá di Modena e Reggio Emilia, Facoltá Di Medicina e Chirurgia, Policlinico, Dipartimento di Emergenza Urgenza

G Gerontol 2008;56:77-84

Aim: The La Peyronie´s and the pseudo La Peyronie´s diseases show recurvatio penis and pain.

Objective: The appearance of the La Peyronie´s diseases and of the pseudo La Peyronie´s diseases in the ederly and its psychological damage have been studied.

Patients and methods: 46 patients, aged 65-72 years (DS 2.12) with La Peyronie´s diseases (23 subjects) and pseudo La Peyronie´s diseases (23 subjects) were enrolled in this study. The diagnosis of the La Peyronie´s diseases and of the pseudo La Peyronie´s diseases was performed by research of clinical and echographic signs. The state of uncomfortable was researched by the Berger questions, the Rosenzweig test and by the medical-patient interviews. Results were evaluated by epidemiological studies (cohort, control-case) and Spearman´s correlations.

Results: The patients with La Peyronie´s diseases suffered of recurvatio penis and pain to erection and showed the uncomfortable in 19 cases, while the patients with pseudo La Peyronie´s diseases suffered of recurvatio penis (it did not connect to erection) and of variable penile pain and showed the uncomfortable in 6 cases. The uncomfortable showed in La Peyronie´s diseases patients 84.29-96.76% of RA (risk in exposed subjects) and 70.31-79.92% of RAP (risk in population) and in pseudo La Peyronie´s diseases patients 50-56.33% of RA and 26.62-33.79% of RAP%. Vascular penile defects can produce the pseudo La Peyronie´s diseases.

Discussion and conclusions: The infectious diseases could induce the La Peyronie´s diseases, while the produced by the lose of the self-esteem (it was identified with the erectile function) and it showed an incidence of the 82.60% in the La Peyronie´s diseases patients and of the 26.08% in the pseudo La Peyronie´s diseases patients.

Key words: Peyronie´s disease - Elderly

Acido urico e marker di infiammazione nella popolazione anziana dello studio InCHIANTI

C. Ruggiero1 2, A. Cherubini2, N.H. Nguyen2, G. Dell´Aquila2, B. Gasperini2, R. Serra1 2, M. Maggio1, F. Lauretani3, S. Bandinelli4, U. Senin2, L. Ferrucci1
1 Sezione Studi Longitudinali, Ricerca Clinica, Istituto Nazionale sull´Invecchiamento, NIH, Baltimore, Maryland, USA;
2 Istituto di Geriatria e Gerontologia, Universitá di Perugia;
3 Agenzia per la Salute, Regione Toscana, Firenze, Italia;
4 A.S.F. Riabilitazione Geriatrica, Firenze

G GERONTOL 2008;56:85-95

Aim: The role of uric acid (UA) in the process of atherosclerosis and atherotrombosis is controversial. Epidemiological studies have recently shown that UA may be a risk factor for cardiovascular diseases and a negative prognostic marker for mortality in subjects with pre-existing heart failure.

Methods: We evaluated a relationship between UA levels and several inflammatory markers in 957 subjects, free of severe renal failure, from a representative Italian cohort of persons aged 65-95. Plasma levels of UA and white blood cell (WBC) and neutrophil count, C-reactive protein (CRP), interleukin-1 receptor antagonist (IL-1ra), interleukin-6 (IL-6), soluble IL-6 receptor (sIL-6r), interleukin-18 (IL-18), and tumor necrosis factor-a (TNF-a) were measured. Complete information on potential confounders was collected using standard methods.

Results
: WBC (p = 0.0001), neutrophils (p > 0.0001), CRP (p < 0.0001), IL-1ra (p < 0.0001), IL-6 (p = 0.0004), sIL-6r (p = 0.002), IL-18 (p < 0.0001), TNF-a (p = 0.0008), and the percentage of subjects with abnormally high levels of CRP (p = 0.004) and IL-6 (p < 0.0001) were significantly higher across UA quintiles. After adjustment for age, sex, behaviour- and disease-related confounders, results were virtually unchanged. In subjects with UA within the normal range, UA was significantly and independently associated with neutrophil count, CRP, IL-6, IL-1ra, IL-18, and TNF-a, whereas non-significant trends were observed for WBC (p = 0.1) and sIL-6r (p = 0.2).

Conclusion
: A positive and significant association between UA and several inflammatory markers was found in a large population-based sample of older persons and in a sub-sample of participants with normal UA. Accordingly, the prevalence of abnormally high levels of C-reactive protein and IL-6 increased significantly across UA quintiles.

Key words
: Uric Acid - Metabolism - Inflammation - Comorbidity - Elderly

Casi clinici

Il ″mal sottile″, una malattia dimenticata in Geriatria: caso clinico

S. Firetto* ***, M. Karin Ghisla* ***, F. Baroni*, E. Facchi*, G. Romanelli** ***
* Fondazione ″Ospedale e Casa Di Riposo - Nobile Paolo Richiedei″ Gussago, Brescia;
** 1A Divisione di Medicina Generale Azienda Ospedaliera Spedali Civili Di Brescia;
*** Universitá di Brescia, Cattedra di Medicina Interna II, Scuola di Specializzazione In Geriatria

G Gerontol 2008;56:103-108

M.G., 83 yrs old female, comes to our attention for hypokinetic syndrome. She reported good health until Feb. 2005, when, after an acute bronchitis episode, a thorax Rx and TC evidences diffused micronodular interstitial morphology; no further investigations were performed at the time.
After a worsening of her motor and cognitive abilities which led in June 2005 to her hospitalization due to debility, delirium, left hemiparesis, moderate nuchal rigidity she was diagnosed with disseminatred TBC (pulmonary and encephalic), anti-tbc therapy was started and the patient was transferred in our Geriatric Rehabilitation Unit. A fast encephalic spreading of the disease and also a rapid worsening of her clinical picture clearly showed the impossibility of any recovery. The patient deceased three month later due to a respiratory crisis.
Tbc is becoming again an emergency in geriatric age, clearly due to endogenous reactivation of old infections. In elderly patients, diagnosis is often issued late, when the disease is already in an advanced stage and the delay results in increased morbidity and mortality rates because of a more extensive lung damage, a more likely extra-lung dissemination and more frequent and more severe complications related to anti-tbc traitements.

Key words: Elderly - Tubercolosis - Diagnosis - Morbility and mortality