Societá

Attivitá SIGG

Giornale di Gerontologia

Numero 6, Dicembre 2007 - Volume LV - Supplemento

Introduzione


Alberto Pilotto
Direttore U.O.C. di Geriatria, Casa Sollievo della Sofferenza,
San Giovanni Rotondo (FG)

Franco Rengo
Presidente FIRI (Fondazione Italiana per la Ricerca sull´Invecchiamento),
Universitá Federico II, Napoli

Bruno Dallapiccola
Direttore Scientifico, Casa Sollievo della Sofferenza,
IRCCS, CSS-Mendel, Roma

G Gerontol 2007;55:1

La quinta edizione degli Incontri di Geriatria 2007 a Casa Sollievo della Sofferenza di San Giovanni Rotondo sono stati dedicati all´Anziano Fragile: dalla diagnosi alla prevenzione. Come é noto la definizione e la caratterizzazione della fragilitá sono argomenti di grande attualitá nel mondo geriatrico nazionale ed internazionale, ancora oggi oggetto di grandi sforzi da parte di ricercatori e clinici che tendono a definire gli aspetti biologici e clinici dell´anziano fragile.
Ci é sembrato doveroso dedicare nei nostri Incontri di Geriatria uno spazio di approfondimento su questo argomento in cui esperti di settore, che da anni si dedicano allo studio e all´assistenza dell´anziano fragile, hanno voluto condividere alcune riflessioni che riteniamo sia utile trasmettere a tutti i colleghi geriatri e agli altri operatori sanitari che si dedicano professionalmente all´anziano. É evidente che la complessitá biologica, clinica ma anche psico-sociale dell´anziano ha colto impreparati non solo la societá e il mondo politico, ma anche la medicina e tutto l´apparato scientifico che, forse con un po´ di ritardo, cerca ora di interpretare le peculiaritá che caratterizzano la comparsa e l´evoluzione della fragilitá dell´anziano.
La disciplina geriatrica da almeno 25 anni cerca di colmare spazi ″vuoti″ culturalmente che circondano l´anziano sia offrendo idee nell´ambito della ricerca di base sia fornendo soluzioni cliniche che siano efficaci per il malato anziano. Al riguardo l´applicazione sempre piú ampia della valutazione multidimensionale e la identificazione di parametri utili per l´approccio clinico dell´anziano fragile potranno permettere di trovare risposte piú adeguate per questa tipologia di pazienti.
Siamo certi che una piú dettagliata definizione biologica e clinica dell´anziano fragile permetterá lo sviluppo di una maggiore attenzione verso la prevenzione; gli esempi portati da alcuni relatori relativi alla prevenzione in ambito di invecchiamento cerebrale, depressione e delle problematiche cardiovascolari ne sono un efficace esempio.
Ringraziamo sinceramente tutti i relatori che con competenza e generositá hanno saputo anche quest´anno arricchire di contenuti significativi gli Incontri di Geriatria 2007. Ci auguriamo sinceramente che la lettura di queste pagine sia un utile spunto di approfondimento professionale per tutti i colleghi e operatori sanitari che dedicano la propria vita professionale al mondo degli anziani.

Copertina

Sommario

LANZIANO FRAGILE: DALLA DIAGNOSI ALLA PREVENZIONE

La fragilitá nell´anziano: una prospettiva clinica

A. Giordano, R. Rozzini, M. Trabucchi*
Fondazione Poliambulanza-Istituto Ospedaliero (Brescia);
* Gruppo di Ricerca Geriatrica (Brescia)

G Gerontol 2007;55:2-6

Frailty denotes a loss of biological reserves (energy, physical ability, cognition, health) that gives rise to vulnerability. It appears to be a valid construct, but how exactly to define it remains unclear. Measuring a proxy of frailty is useful at a health care policy level as well as clinically; information about frailty help program planners to identify the range of services that might be required to prevent the occurrence of health impairment. Clinically, frailty stratification can be useful to plan medical interventions or to predict a patient´s risk of death or need for institutional care. In these review we present some clinical indicators of frailty, like chronic diseases, delirium, functional loss after a clinical acute event, and lack of recovery after an acute disease.

Key words: Frailty - Functional status - Delirium

Il Multidimensional Prognostic Index (MPI) per la valutazione dell´anziano fragile ospedalizzato

A. Pilotto*, M. Franceschi*, L. Ferrucci**
* Unitá Operativa Geriatria & Laboratorio di Ricerca Gerontologia-Geriatria, Casa Sollievo della Sofferenza, IRCCS, San Giovanni Rotondo (FG);
** National Institute on Aging, longitudinal Studies Section, Harbor Hospital Center, Baltimore, MD, USA

G Gerontol 2007;55:7-10

The Comprehensive Geriatric Assessment (CGA) is the first-choice tool for evaluating biological, functional, cognitive, social and clinical aspects of elderly subjects. CGA may be useful in the frail elderly, particularly when it is carried out as a combination of hospital- ward and community services for the elderly. Very recently a Multidimensional Prognostic Index (MPI) was developed from CGA data obtained from 838 hospitalized elderly patients by aggregating the total scores of 8 domains and 63 items. Thereafter, MPI was validated in a cohort of 857 elderly hospitalized patients. In both the cohorts, a close agreement was found between the estimated mortality and the observed mortality after both 6-month and 1-year of follow-up. The discrimination of the MPI was also good when applied in patients with upper gastrointestinal bleeding, metabolic syndrome, pneumonia and dementia. This MPI, calculated from information collected in a standardized CGA, accurately stratifies hospitalized elderly patients into groups at varying risk of mortality and it is very useful for clinical and research purposes.

Key words: Comprehensive Geriatric Assessment - Frail elderly - Multidimensional Prognostic Index

Nutrizione, esercizio fisico ed invecchiamento ottimale

L. Fontana
Dipartimento di Sanitá Alimentare e Animale, Istituto Superiore di Sanitá; Division of Geriatrics and nutritional Science and Center for Human nutrition, Washington University School of Medicine, St. Louis, Missouri, USA

G Gerontol 2007;55:11-14

Excessive energy intake, a sedentary lifestyle, and subsequent visceral obesity are associated with impaired function of most organ systems, serious medical diseases, and premature mortality. Weight loss, induced by a negative energy balance, simultaneously improves multiple cardiometabolic and hormonal risk factors and decrease cardiovascular and cancer mortality rate in overweight patients. Furthermore, a reduction in calorie intake below usual ad libitum intake has been shown to prevent/delay age-associated chronic diseases and to extend maximal lifespan in rodents. Whether or not CR increases maximal longevity in humans remains an unanswered question. However, preliminary evidence suggests that humans eating nutrient-rich CR diets develop some of the same adaptations to CR that occur in long-lived rats and mice. Long-term CR with adequate nutrition decreases insulin resistance, inflammation, dyslipidemia, blood pressure, growth factors, and alters positively neuroendocrine function. These are among the adaptations that have been hypothesized to mediate the slowing of aging and protection against type 2 diabetes, cardiovascular disease and cancer by CR in rodents.

Key words: Nutrition, calorie restriction, exercise, adiposity, aging

I diritti dell´anziano fragile: una prospettiva etica

M. Petrini
Centro di Promozione e Sviluppo dell´Assistenza Geriatrica, Dipartimento di Scienze Geriatriche, Gerontologiche e Fisiatriche, Facoltá di Medicina e Chirurgia ″A. Gemelli″, Universitá Cattolica del Sacro Cuore, Roma

G Gerontol 2007;55:15-19

Humanity means frailty, weakness, illness, disability, trauma, ageing, and numerous other signs of mortality. However, the social consideration of frailty varies along life´s course. Much is said about in connection with old age, but it certainly is not interpreted with the same care.
Today, there is a need to affirm that the frail elderly have the right to avail of the same support services and to be treated with the same dignity and quality of life as any other member of society.

Key words: Frail elderly - Geriatric ethics - Quality of life

FRAGILIT E CERVELLO

Prevenzione della demenza: mito o realtá?

A. Capurso*, V. Solfrizzi*, A. D´Introno*, A.M. Colacicco*, C. Capurso**, G. Pistoia*, A. Gadaleta*, R. Menga*, A. Santamato***, A. Pilotto****, D. Seripa*****, F. Panza*
* Cattedra di Geriatria, Centro per lo Studio dell´Invecchiamento Cerebrale, Memory Unit, Universitá di Bari;
** Cattedra di Geriatria, Universitá di Foggia;
*** Cattedra di Medicina Fisica e riabilitazione, Universitá di Foggia;
*** Dipartimento di Geriatria, Casa Sollievo della Sofferenza, IrCCS, San Giovanni rotondo (FG);
***** laboratorio di Geriatria e Gerontologia, Dipartimento di ricerca, Casa Sollievo dalla Sofferenza, San Giovanni rotondo (FG)

G Gerontol 2007;55:20-26

Cognitive decline and dementia have a deep impact on the health state and quality of life of older subjects and their caregivers. Since the therapeutic options currently available have demonstrated limited efficacy, the search for preventive strategies for cognitive decline and dementia are mandatory. A possible role of lifestyle-related factors was recently proposed for age-related changes of cognitive function, predementia syndrome and the cognitive decline of degenerative (Alzheimer´s Disease, AD) or vascular origin. At present, cumulative evidence suggested that vascular risk factors may be important in the development of Mild Cognitive Impairment (MCI), dementia, and AD. Moderate alcohol drinking has been proposed as a protective factor against MCI and dementia in several longitudinal studies, but contrasting findings also exist. The Mediterranean diet could be therefore an interesting model to further study the association between dietary patterns and cognitive functioning, given the suggested role of many components of this diet (monounsaturated fatty acids, polyunsaturated fatty acids, and red wine) in contrasting cognitive impairment and dementia. The association between low education and predementia and dementia syndromes is supported by the majority of studies, but very few studies have investigated whether this association may be attributed with lifestyle factors that covary with education. At present, in older subjects, healthy diets, antioxidant supplements, and the prevention of nutritional deficiencies could be considered the first line of defense against the development and progression of predementia and dementia syndromes. However, in most cases, these were only observational studies, and results are awaited from large multicenter randomized clinical trials in older persons.

Key words: Dementia - Mild cognitive impairment - Monounsaturated fatty acids - Polyunsaturated fatty acids - Diet - Alcohol - Alzheimer´s disease - Vascular dementia

La terapia farmacologica della depressione nell´anziano

P.L. Scapicchio
Docente di Neurologia e Psichiatria Geriatria, Universitá Cattolica del Sacro Cuore, Policlinico
Agostino Gemelli, Roma

G Gerontol 2007;55:27-30

Pharmacological treatment of depression in the elderly needs to pay great attention to safety and tolerability of drugs, their dosages, istruction on their use and compliance of the patient. It is important also to consider the resistance to antidepressant treatment as well as to pharmacological aspects related to the cythochrome P-450 metabolism.

Key words: Treatment of depression in the elderly - Antidepressants

FRAGILIT E CUORE

Anziano fragile e prevenzione cardiovascolare

Francesco Rengo, E. Avallone, P. Donnarumma, M. Abitabile, Franco Rengo
Cattedra di Geriatria, Universitá Federico II, Napoli

G Gerontol 2007;55:31-34

The reduction of cardiovascular risk factors, the introduction of novel drug therapies, and invasive percutaneous and cardiac surgery techniques, have contributed to reduce cardiovascular events in the global population. However, the main reduction of mortality rate, since ´70s to nowadays, has been obtained by these novel therapeutic strategies in subjects < 65 years of age. Significant changes in lifestyle are shown to significantly blunt the unfavourable and independent effect of aging on cardiac prognosis. In this vein, an active lifestyle, alone or combined with caloric restriction and a normal BMI are able to prevent cardiovascular diseases in the elderly. Several mechanisms may account for the favourable effects of life style on outcome in the older. Ischemic preconditioning has been proposed as an endogenous protective mechanism against ischemia and it seems to be loss with aging. Exercise training combined with food restriction restore ischemic preconditioning, and reduce mortality and cardiogenic shock in elderly patient with AMI.

Key words: Elderly - Physical activity - Food restriction - Cardiovascolar prevention

Ipertensione arteriosa e rischio cardiovascolare nell´anziano

C. Vitale, M. Fini
Dipartimento di Scienze Mediche, Unitá di Ricerche Cardiovascolari, iRCCS San Raffaele, Roma

G Gerontol 2007;55:35-39

Arterial hypertension is a major risk factor for cardiovascular (CV) morbidity and mortality also in the elderly. Isolated systolic hypertension is the most frequent form of arterial hypertension in this population and is due to both structural and functional changes in large arteries. These are responsible for the increase in systolic blood pressure with concomitant decrease in diastolic pressure. Although all antihypertensive drugs lower effectively blood pressure and reduce cardiovascular and cerebrovascular mortality and morbidity, arterial hypertension remains uncontrolled in most elderly patients.

Key words: Elderly - Hypertension - Stiffness

Prevenzione del tromboembolismo venoso nell´anziano nel 2007: nuove strategie antitrombotiche nel paziente medico e chirurgico

M. Di Minno, A. Tufano, A. Pilotto*, A. De Gregorio, M. De Capua, G. Di Minno*
Dipartimento di Medicina Clinica e Sperimentale, Centro di Coordinamento Regionale per le Emocoagulopatie, Universitá di Napoli ″Federico II″;
* IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo (FG)

G Gerontol 2007;55:40-47

Venous thromboembolism (VTE) is the third most common cause of cardiovascular disease in the general population. It is especially common in the elderly, its incidence being maximal in individuals older than 60 yrs of age: if the incidence in the general population is 1/1000 individuals/yr, after the 80s it is 3-fold higher. The pathogenesis of VTE is multifactorial, involving genetic determinants (hereditary thrombophilia, deficiency of natural anticoagulants, Factor V Leiden mutation, prothrombin G20210A mutation) as much as environmental conditions (surgery/trauma, HRT/oral contraception, malignancy, antiphospholipid syndrome, medical settings such as myocardial infarction, congestive heart failure, ischemic stroke with paralysis of the lower limbs). The co-existence of multiple factors enhances the risk of events, especially in older settings. In this respect, in older patients with medical risk factors undergoing surgical procedures, the risk of VTE will be higher than the risk associated with surgery alone or medical conditions alone (co-existence of elderly + medical + surgical risk factors). In this review, major recommendations on prevention of VTE in medical and surgical patients and in major risk categories, as summarized in the recent Guidelines of the American College of Chest Phisicians (ACCP) will be discussed, with emphasis on older patients and on recent major randomized clinical trials in such setting. Alone or together with physical strategies, heparin and low-molecular weight heparins (LMWH) are recommended drugs for this prophylaxis. Newer anticoagulants (mainly fondaparinux) exhibit efficacy/safety profile as good as LMWH for thrombophrophylaxis.

Key words: Pulmonary embolism, stroke, venous tromboembolism, prevention

Sindrome metabolica e fragilitá nell´anziano

G. Vendemiale
Cattedra e Scuola di Specializzazione in Geriatria, Universitá di Foggia; U.O.C. di Medicina interna, Casa Sollievo della Sofferenza, San Giovanni Rotondo (FG)

G Gerontol 2007;55:48-53

The metabolic syndrome (MS) is a cluster of metabolic abnormalities leading to increased risk for cardiovascular diseases. Aging is associated to a high prevalence of the syndrome, going from ~25% in the middle age up to ~45% in older population (60-69 yrs and over). The major criteria which outline the MS are represented by visceral obesity, hypertension, derangement of glucidic and lipidic metabolism, also with a central hepatic involvement and a pro-thrombotic and inflammatory state. Insulin resistance (IR) represents most likely the main pathogenic mechanism leading to increased liver triglyceride (TG) content and steatosis. The imbalance of the mitochondrial beta-fatty acid oxidation leads to alternative oxidative pathways responsible for reactive oxygen species production which in turn activate a number of toxic cytokines such as TGF-, TNF-a, inflammatory interleukins which play a major role in fibrogenetic and inflammatory processes. In the liver FFA are oxidised and serve as substrate for neoglucogenesis and excess TG production. These alterations lead to decreased HDL levels and increased small dense highly atherogenic LDL particles which induce impairment of endothelial function. IR is also implicated in the activation of RAA system, NA retention and stimulation of the sympathetic nervous system, all conditions leading the increased blood pressure. Visceral obesity and IR share several pathogenic mechanisms, the one being responsible for the other and vice-versa. Excess visceral adiposity produces high amounts of TNF-a which induces IR. Advancing age affects all levels of MS components. Aging is associated with a redistribution of the body composition in favour of the adipose tissue with a decrease of lean body mass. The adipose tissue is especially marked centrally which favours IR. The decreased muscle mass and strength causes reduced physical activity and a frailty status activating a vicious circle leading to obesity and worsening all the MS complications.

Key words: Metabolic syndrome - Aging - Frailty