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Lisanne Tap,1 Lisanne J Dommershuijsen,1 Andrea Corsonello,2 Fabrizia Lattanzio,2 Silvia Bustacchini,2 Gijsbertus Ziere,1 Jan LCM van Saase,3 Francesco US Mattace-Raso1 1Section of Geriatric Medicine, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands; 2Italian National Research Center on Aging (INRCA), Ancona, Fermo and Cosenza, Italy; 3Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the NetherlandsCorrespondence: Francesco US Mattace-RasoSection Geriatric Medicine, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Room Rg-527, PO BOX 2040, Rotterdam 3000 CA, the NetherlandsTel +31 10703 5979Fax +31 10703 47 68Email f.mattaceraso@erasmusmc.nlPurpose: Aortic stiffness (AS) is associated with cardiovascular events and all-cause mortality in the older population. AS might also influence the health-related quality of life (HRQOL) as a result of the negative effects of AS on cognitive and physical morbidity. We aimed to investigate the possible association between AS and HRQOL in people aged 75 years and over.Patients and Methods: This cross-sectional study was part of the SCOPE study, an international multicenter cohort observational study. The indicators for AS were aortic pulse wave velocity (aPWV) and central pulse pressure (cPP). HRQOL was assessed using the EQ-5D index and the EQ-5D visual analog scale (VAS). ANCOVA and multivariate regression models were used to investigate possible associations.Results: We included 280 Dutch participants of the SCOPE study. Median age was 79 years (IQR 76– 83) and 42.1% were women. Participants reporting any problem on the EQ-5D index (n=214) had higher values of aPWV (12.6 vs 12.2 m/s, p = 0.024) than participants not experiencing any problem (n=66) and comparable values of cPP (44.4 vs 42.0 mmHg, p = 0.119). Estimates only slightly changed after adjustments. No association was found between indicators of AS and EQ-5D VAS.Conclusion: Aortic stiffness was associated with impaired quality of late life. This association could be mediated by subclinical vascular pathology affecting mental and physical health.Keywords: arterial stiffness, health-related quality of life, EQ-5D, older persons

Aim To describe the methods and feasibility of the nutritional intervention carried out within the SPRINTT Randomized cotrolled trial. We also illustrate how nutrition interventionists identified participants at risk of malnutrition and the lessons learnt from the nutrition intervention. Findings SPRINTT nutrition intervention was well-received by the majority of the participants. It was mainly carried out using tailored nutrition counselling, but also other means of delivering the intervention were successfully used. Compared with a standard nutrition prescription, an individualized protocol to diagnose malnutrition and follow-up by tailored nutrition counselling helped achieve nutritional targets more effectively in spite of diversity of population in nutritional habits and in some cases reluctance to accept changes. Message The SPRINTT nutrition intervention was feasible and allowed flexibility to the varying needs and cultural differences of this heterogeneous population of frail, older Europeans. It may serve as a model to educate and improve nutrition among community-dwelling older people at risk of mobility limitations. Supplementary Information The online version contains supplementary material available at 10.1007/s41999-020-00438-4., Background The “Sarcopenia and Physical Frailty in Older People: Multicomponent Treatment Strategies” (SPRINTT) project sponsored a multi-center randomized controlled trial (RCT) with the objective to determine the effect of physical activity and nutrition intervention for prevention of mobility disability in community-dwelling frail older Europeans. We describe here the design and feasibility of the SPRINTT nutrition intervention, including techniques used by nutrition interventionists to identify those at risk of malnutrition and to carry out the nutrition intervention. Methods SPRINTT RCT recruited older adults (≥ 70 years) from 11 European countries. Eligible participants (n = 1517) had functional limitations measured with Short Physical Performance Battery (SPPB score 3–9) and low muscle mass as determined by DXA scans, but were able to walk 400 m without assistance within 15 min. Participants were followed up for up to 3 years. The nutrition intervention was carried out mainly by individual nutrition counseling. Nutrition goals included achieving a daily protein intake of 1.0–1.2 g/kg body weight, energy intake of 25–30 kcal/kg of body weight/day, and serum vitamin D concentration ≥ 75 mmol/L. Survey on the method strategies and feasibility of the nutrition intervention was sent to all nutrition interventionists of the 16 SPRINTT study sites. Results Nutrition interventionists from all study sites responded to the survey. All responders found that the SPRINTT nutrition intervention was feasible for the target population, and it was well received by the majority. The identification of participants at nutritional risk was accomplished by combining information from interviews, questionnaires, clinical and laboratory data. Although the nutrition intervention was mainly carried out using individual nutritional counselling, other assisting methods were used as appropriate. Conclusion The SPRINTT nutrition intervention was feasible and able to adapt flexibly to varying needs of this heterogeneous population. The procedures adopted to identify older adults at risk of malnutrition and to design the appropriate intervention may serve as a model to deliver nutrition intervention for community-dwelling older people with mobility limitations. Supplementary Information The online version contains supplementary material available at 10.1007/s41999-020-00438-4.

Background:There is consensus that dementia is the most burdensome disease for modern societies. Few cost-of-illness studies examined the complexity of Alzheimer's disease (AD) burden, considering at the same time health and social care, cash allowances, informal care, and out-of-pocket expenditure by families.Methods:This is a comprehensive cost-of-illness study based on the baseline data from a randomized controlled trial (UP-TECH) enrolling 438 patients with moderate AD and their primary caregiver living in the community.Results:The societal burden of AD, composed of public, patient, and informal care costs, was about €20,000/yr. Out of this, the cost borne by the public sector was €4,534/yr. The main driver of public cost was the national cash-for-care allowance (€2,324/yr), followed by drug prescriptions (€1,402/yr). Out-of-pocket expenditure predominantly concerned the cost of private care workers. The value of informal care peaked at €13,590/yr. Socioeconomic factors do not influence AD public cost, but do affect the level of out-of-pocket expenditure.Conclusion:The burden of AD reflects the structure of Italian welfare. The families predominantly manage AD patients. The public expenditure is mostly for drugs and cash-for-care benefits. From a State perspective in the short term, the advantage of these care arrangements is clear, compared to the cost of residential care. However, if caregivers are not adequately supported, savings may be soon offset by higher risk of caregiver morbidity and mortality produced by high burden and stress. The study has been registered on the website www.clinicaltrials.org (Trial Registration number: NCT01700556).

The availability of family caregivers of older people is decreasing in Italy as the number of migrant care workers (MCWs) hired by families increases. There is little evidence on the influence of socioeconomic factors in the employment of MCWs.We analyzed baseline data from 438 older people with moderate Alzheimer's disease (AD), and their family caregivers enrolled in the Up-Tech trial. We used bivariate analysis and multilevel regressions to investigate the association between independent variables-education, social class, and the availability of a care allowance-and three outcomes-employment of a MCW, hours of care provided by the primary family caregiver, and by the family network (primary and other family caregivers).The availability of a care allowance and the educational level were independently associated with employing MCWs. A significant interaction between education and care allowance was found, suggesting that more educated families are more likely to spend the care allowance to hire a MCW.Socioeconomic inequalities negatively influenced access both to private care and to care allowance, leading disadvantaged families to directly provide more assistance to AD patients. Care allowance entitlement needs to be reformed in Italy and in countries with similar long-term care and migration systems.

Objectives: Guidelines for the screening, treatment, and monitoring of modifiable cardiovascular risk factors such as hypertension (HTN) and dyslipidemia (DYS), have been developed to assist physicians in lowering the global risk of cardiovascular disease (CVD). This study assessed the management of patients with these conditions in a primary care setting in Italy. Methods: This was a retrospective cohort study conducted in 2000–2002 using the Italian Health Search Database (HSD). The management of HTN (blood pressure [BP] 140/90 mmHg) and DYS (total cholesterol 5 mmol/L [193 mg/dL]) was assessed by measuring the numbers of patients screened for one or both conditions, the numbers treated pharmacologically, and the numbers monitored for treatment success. Management patterns were stratified by history of cardiovascular events. Results: Blood pressure screening at a population level was approximately 35% for HTN in each year whereas for DYS, it increased from 26% in 2000 to 32% in 2002. Over the study period, the prevalence of HTN increased from 19% to 23%, whereas the prevalence for DYS doubled (from 14% to 28%). For both HTN and DYS these prevalences were substantially lower than national survey estimates (23% versus 48% for HTN and 16% versus 57% for DYS in 2001). Among patients with newly identified HTN or DYS, eligible for reimbursed pharmacological treatment, 26% and 82%, respectively, were not treated within 1 year of diagnosis. Treatment levels were higher in patients with a history of CVD, but were still far from optimal. Monitoring of BP and cholesterol in the first year of treatment was sub-optimal e.g. 36% of newly-treated HTN patients had no record of a BP evaluation and 32% of newly-treated DYS patients had no record of a cholesterol assessment. Blood pressure monitoring was slightly higher in patients with a history of CVD. Extrapolation to all new HTN and DYS patients showed that less than 50% of patients with HTN and 12% of those with DYS were adequately treated or monitored. Conclusion: The differences between the prevalence of recorded HTN or DYS and national survey results suggest extensive underscreening and underdiagnosis of these conditions. Overall, this study highlights the need to improve the management of patients with HTN and DYS.

Associations between copper to zinc ratio (CZr) and mortality have suggested CZr as a biomarker of aging. Nevertheless, very limited data exist on the association between serum CZr and physical or functional status of very old people. We examined the relationship between serum CZr and physical performance, muscle strength, functional status, and survival from the ilSIRENTE Study: a longitudinal study of persons aged 80 years or older (n = 346). An adjusted linear regression model was subsequently performed to calculate the regression coefficients of the associations between baseline physical and functional measures (dependent variable) with CZr or “Cu and Zn” alone taking also into account the influence of other relevant factors, including hematological (albumin, cholesterol, and urea) and inflammatory biomarkers (IL-6 and CRP) that were significantly different across CZr tertiles. CZr showed significant and stronger relationships than Cu or Zn alone with all baseline physical and functional measures in models that did not include adjustments for inflammatory parameters. CZr was also associated with physical decline, measured as “SPPB% decline” at 2 years of follow-up and mortality at 4 years of follow-up. Subjects in the high CZr tertile had a higher risk of death with an adjusted hazard ratio of 1.92 (95% CI, 1.12–3.29; p = 0.02). In conclusion, we have confirmed the role of CZr as a predictor of mortality, whereas the role of CZr as a biomarker or predictor of physical or functional performance seems to be the consequence of its strict relationships with inflammatory parameters. In this context, further investigations need to be carried out.

The most frequent cause of mortality and morbidity in industrialized countries is coronary artery disease (CAD), which in Europe alone is responsible for around two million deaths per year. In 2001 it accounted for about 260,000 hospital discharges in Italy. The costs of CAD treatment in Italy--which were borne by the Italian state, the third-party payer--amounted to 800 million euros. We propose to assess the pharmacoeconomic implications of using amlodipine besylate treatment in Italy for patients with coronary artery disease. The study is based on a post-hoc cost-effectiveness analysis that compared standard care supplemented by amlodipine besylate with ordinary standard care over a 36-month time horizon. The clinical outcome data were based on the prospective randomized evaluation of vascular effect of norvasc trial (PREVENT). Direct medical costs referred to the purchase costs of amlodipine besylate and the cost of National Health Service (NHS) hospitalization. The costs were discounted back at an annual rate of 5%. Patients administered amlodipine besylate exhibited a significant risk reduction with respect to any major vascular event or procedure when compared to the placebo group. The reduction mainly referred to unstable angina events and revascularization procedures. We estimated that the total cost of adding amlodipine besylate to standard care amounted to 139,050 euros per 1000 patients treated for 36 months. This represents a cost of 1780 euros per patient remaining free of any vascular event. Results were sensitive to both clinical and economic variables. The incremental costs of the alternative therapy ranged from 296 euros to 5066 per patient free of any event in, respectively, the best and worst scenario. Amlodipine besylate therapy can be a cost-effective strategy for CAD treatment in Italy. Our economic evaluation demonstrated, first, that by reducing vascular events and the need for revascularization procedures savings were achieved in hospital expenditure, and, second, that such savings could significantly offset drug costs.

Adverse drug events (ADEs) are an increasingly relevant issue for healthcare systems as they are associated with poorer health outcomes and avoidable misuse of resources. The rates of ADEs are higher in the elderly population, as many older patients have comorbidities, multiple drug prescriptions and deteriorated physical and cognitive functioning. The occurrence of ADEs can lead to a perceived lack of therapy efficacy and further underuse or suboptimal adherence in elderly people, with detrimental clinical outcomes. The present article systematically reviews the studies evaluating the economic impact of ADEs occurring as consequence of poor therapy adherence, inappropriate drug use, underuse of effective treatments and poor adherence, medication errors, drug-drug and drug-disease interactions. A Medline systematic literature review of studies evaluating the economic consequences of inappropriate drug prescribing, lack of adherence and compliance, ADEs in older people was performed. English-language articles were screened through a three-step approach (title review, abstract review, full article review) to select pertinent studies quantitatively evaluating costs. We systematically reviewed evidence from767 articles. After title, abstract and full text review, 21 articles were found to measure economic implications ofADEs, inappropriate drug prescribing and poor adherence in elderly patients. Studies suggested that the economic impact of these undesired effects is substantial: hospital costs were the main cost driver, with a relevant part of them being preventable (consequences of inappropriate prescribing). Healthcare costs for unused drug wastage and destruction were also surprisingly high. Although economic evidence in elderly patients is still limited, all studies seemed to confirm that the financial burden due to pharmacological treatment issues is relevant in elderly people. Including economic effects of adverse events in pharmacoeconomic analysis would be beneficial to improve the reliability of results. Preliminary evidence suggests that programmes aimed at comprehensively assessing geriatric conditions, detecting 'high-risk' prescriptions and training patients to comply with prescribed therapies could be costeffective measures to reduce the burden of ADE. Adis © 2012 Springer International Publishing AG. All rights reserved.

Purpose of review: Chronic obstructive pulmonary disease (COPD) is a high prevalence condition with a significant clinical and economic burden. In elderly people, COPD is often associated with other chronic comorbidities (i.e. cardiovascular diseases), determining clinical complications and requiring frequent acute healthcare interventions. The aim of this article is to review the economic studies evaluating costs and healthcare resource utilization in elderly (≥65 years) COPD patients. Recent findings: Sixteen of the initial 359 articles retrieved through our research strategy were found to include relevant cost information on elderly COPD patients or to evaluate the effect of older age on healthcare expenditure. Most studies were carried out in the United States and used administrative database claims to determine resource consumption and direct costs (attributable and not). Very few studies focused exclusively on elderly patients. Summary: Results showed a certain variability of cost estimations, mainly due to the different methodologies and adopted cost approach. However, we found a trend of direct cost growth in the elderly population, which can be explained by a more frequent use of acute healthcare services, especially for managing COPD exacerbations. These results cannot be considered definitive and new studies, targeting elderly people, are required in order to confirm these preliminary findings. © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins.

Life expectancy has significantly increased over the past 30 years, with a greater prevalence of diverse disease states, especially type 2 diabetes mellitus. As older persons are a very heterogeneous group with an increased prevalence of comorbidities and a relative inability to tolerate the adverse effects of oral antidiabetic agents, the treatment of type 2 diabetes is particularly demanding. The principles of its management are similar to those in younger patients, but with special considerations linked to comorbidities and clinical status. The available oral antidiabetic drugs include insulin secretagogues (meglitinides and sulfonylureas), biguanides (metformin), alpha-glucosidase inhibitors, thiazolidinediones and newly introduced inhibitors of glucagon-like peptide 1 degrading enzyme dipeptidyl peptidase 4 (DPP-4). In addition, clinical aspects complicate diabetes care in the elderly, including cognitive disorders, physical disability and geriatric syndromes, such as frailty. The European Diabetes Working Party for Older Persons has increased glycaemic recommendations for target haemoglobin A(1c) from

In Italy, revascularization interventions increased from 44,600 in 1996 to more than 100,000 in 2001. In particular, the occurrence of percutaneous transluminal coronary angioplasty (PTCA) increased from 239 cases per million population in 1994 to about 1300 cases per million population in 2001. This trend has caused a concomitant increase in revascularization costs, which have doubled in few years, rising from Euro 421 millions in 1996 to Euro 850 millions in 2001. In 2001, PTCA amounted to 55% of total cost of revascularizations. The aim of this study was to assess the pharmacoeconomic consequences of amlodipine besylate therapy administered in patients at high risk of restenosis after PTCA. We conducted a cost-effectiveness analysis comparing therapy with amlodipine besylate added to standard care versus standard care alone. Information on clinical outcomes was drawn from the Coronary Angioplasty Amlodipine Restenosis Study (CAPARES). Medical costs were estimated with reference to drug therapy and hospitalizations for coronary events and revascularization procedures. The study was conducted from the perspective of the Italian third party payer (National Health Service). The analysis was applied to a time horizon of 4 months. Amlodipine besylate resulted less expensive and more effective than standard care. It reduced mortality, morbidity for coronary reasons and the need of revascularization procedures. The cost per 1000 patients was estimated at Euro 1,166,000 in the placebo and Euro 950,000 in the amlodipine besylate group, resulting into a cost saving of Euro 216,000, that is 18.5% of total cost of standard care. Results are sensitive to the cost of amlodipine besylate and the cost of hospitalizations, but therapy with amlodipine besylate resulted dominant even in the most unfavorable hypothesis.