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Key summary points Aim To meet the current need in different European countries for improving prescribing in older adults, we aimed to create an update screening tool getting origin from the two user friendly criterion sets: the STOPP/STARTv2 criteria and CRIME criteria. Findings Based on thorough literature review, 55 criteria were added, 17 criteria were removed, and 60 criteria were modified. As a result, 153 TIME criteria composed of 112 TIME-to-STOP and 41 TIME-to-START criteria were introduced. Message TIME criterion set is an update screening tool reported from Eastern Europe that included experts from geriatrics and other specialties frequently giving care to older adults and some additional practical explanations for clinical use. Electronic supplementary material The online version of this article (10.1007/s41999-020-00297-z) contains supplementary material, which is available to authorized users., Purpose To improve prescribing in older adults, criterion sets have been introduced from different countries. While current criterion sets are useful to some extent, they do not meet the need in some European countries. Turkish inappropriate medication use in the elderly (TIME) criteria was planned to meet this need. Methods In phase 1, the user friendly sets: STOPP/START version2 and CRIME criteria were combined. National experts composed of geriatricians and non-geriatricians were invited to review and comment. In phase 2, thorough literature review was performed and reference-based revisions, omissions, and additions were made. Explanatory additions were added to some criteria to improve application in practice. In phase 3, all working group members reviewed the criteria/explanations and agreed on the final content. Results Phase 1 was performed by 49 expert academicians between May and October 2016. Phase 2 was performed by 23 working group academicians between October 2016 and November 2018 and included face-to-face interviews between at least two geriatrician members and one criterion-related specialist. Phase 3 was completed between November 2018–March 2019 with review and approval of all criteria by working group academicians. As a result, 55 criteria were added, 17 criteria were removed, and 60 criteria were modified from the first draft. A total of 153 TIME criteria composed of 112 TIME-to-STOP and 41 TIME-to-START criteria were introduced. Conclusion TIME criteria is an update screening tool that differs from the current useful tools by the interactive study of experts from geriatrics and non-geriatrics, inclusion of practical explanations for some criteria and by its eastern European origin. TIME study respectfully acknowledges its roots from STOPP/START and CRIME criteria. Studies are needed whether it would lead improvements in older adults’ health. Electronic supplementary material The online version of this article (10.1007/s41999-020-00297-z) contains supplementary material, which is available to authorized users.

Objective: Polypharmacy, an important geriatric syndrome, has been shown to be an independent risk factor for falling. However, the data about effects of polypharmacy on balance is lacking. We aimed to evaluate the effects of polypharmacy and inappropriate drug use on balance in older adults. Patients and Methods: Fifty-one patients using ≥ 5 drugs and 50 patients using < 5 drugs were included in the study. Inappropriate drug usage of the patients was evaluated by Beers criteria. Postural stability and risk of falling was investigated by using Biosway Portable Balance System (BPBS). Activities and functional status of the patients were assessed by using Short Physical Performance Battery (SPPB) and Activities Specific Balance Confidence Scale (ABC). All patients underwent comprehensive geriatric assessment. Results: Age, gender, hand grip strength, SPPB scores of the patients were similar between polypharmacy and control groups (all had p>0.05). ABC score was higher in polypharmacy group than control (p

Many factors affecting noninvasive ventilation (NIV) in critically ill patients have been reported in the literature, but there is no study about the effect of frailty. With this study, the frailty prevalence was evaluated with two different frailty scores among the NIV population of a medical intensive care unit (ICU). Besides, the impact of frailty on NIV success and mortality and its association with NIV application problems were evaluated. A prospective observational cohort study was performed on patients who were over 50 years of age and assigned to NIV due to hypercapnic respiratory failure. For the assessment of frailty, Clinical Frailty Scale (CFS) and The Edmonton Frailty Scale (EFS) were used and the ones with CFS ≥5 and EFS ≥8 were considered as fragile. The study population was classified and compared according to NIV success, ICU outcome (discharge or exitus) and NIV application problems. A total of 103 patients with the mean age of 73 ± 11 years were included. The incidence of frailty was 41% with CFS ≥5 and 36% with EFS ≥8. The NIV failure occurred in 30 (29%) patients. Among them frailty and SOFA score was higher; Glasgow Coma Scale (GCS) was lower. In multivariate analysis GCS (OR: 1.2, p: 0.042) and frailty with EFS (OR: 2.8, p: 0.027) were identified as independent risk factors of NIV failure. Sixty-five (63%) patients had NIV application problems and frailty was higher among them with both CFS and EFS (p

Malnutrition is a common problem in gastrointestinal cancer patients and affects all aspects of oncology treatment, including treatment response, toxicity, performance status, quality of life, and overall survival. However, it is usually underappreciated or underestimated among healthcare professionals as a result of low awareness, although there is growing evidence showing that it can be prevented or reduced through nutritional interventions. Therefore, nutritional screening and support should be considered for all cancer patients. This chapter focuses specifically on the nutrition of gastrointestinal cancer patients. The following topics are reviewed: cancer cachexia (definition, prevalence, assessment, mechanism, and management); prevalence and adverse outcomes of malnutrition, nutritional screening/assessment to identify potential candidates for nutritional support; nutritional requirements, timing of nutrition, routes of delivering nutritional support (enteral versus parenteral), indications; and results of nutritional support (in perioperative period, during radiation therapy and/or chemotherapy, in incurable patients).

Incidences of overactive bladder (OAB) and cognitive dysfunction increase with aging. Treatment of OAB with antimuscarinic agents may result in cognitive decline, especially in patients with Alzheimer's disease (AD). The aim of this study is to evaluate the effect of antimuscarinic treatment on cognitive functions, depression, and quality of life (QOL) of patients with OAB.This non-interventional prospective observational study was conducted in a geriatric medicine outpatient clinic. Overall, 168 OAB patients were enrolled. Patients were followed up in five groups: oxybutynin, darifenacin, tolterodine, trospium, and control groups. Follow-up visits were done at second, third, and sixth months. Comprehensive geriatric assessment, cognitive and mood assessment, QOL scales (IIQ-7, UDI-6) were performed.Mean age of the patients was 73.5 ± 6.1. Of the 168 patients, 92.3% were female, 83.3% benefited from the treatment, and 37.1% discontinued the medication. Discontinuation rate and frequency of side effects were more frequent in the oxybutynin group. Mini Mental State Examination scores did not decline after treatment, even in AD patients. Geriatric Depression Scale scores, Activities of Daily Living scores, and QOL scores significantly improved after treatment.Antimuscarinic agents are effective in OAB treatment. They have a positive impact on daily life activities, depression, and QOL indices. Furthermore, they do not have a negative effect on cognitive function in older adults with or without AD.

The WHO reports that one of the major chronic conditions affecting the elderly worldwide is musculoskeletal disorders that are associated with long-term pain and disability. Considering the healthcare needs of the elderly (i.e. comprehensive, accessible, efficient) and the advantages of ultrasound (US) use (patient-friendly, convenient, cost-effective, and does not require exposure to radiation or magnetic fields), there seems to be a 'gap' in the actual clinical practice. In this paper, we aimed to highlight the potential value of US imaging in the management of the elderly with a wide spectrum of musculoskeletal conditions (degenerative/rheumatic joint diseases, falls/trauma, nursing care, peripheral nerve problems, sarcopenia, and interventions). In this respect, electronic databases (ISI Web of Science, PubMed, Elsevier Science Direct) and reference lists of relevant articles/reviews were screened by two blinded investigators for each topic. The main medical subject heading terms selected to capture the most relevant papers on the topics in accordance with the literature were knee/hip/hand osteoarthritis, prevalence, rotator cuff injury, lateral epicondylitis, tendinopathy, rheumatoid arthritis, Sjogren's syndrome, polymyalgia rheumatica, crystal arthropathies, gout, pseudogout, carpal tunnel syndrome, fall, fractures, hematoma, pressure ulcer, ultrasonography, interventional, sarcopenia, body composition, rehabilitation, frail elderly, and aged. The search was limited to peer-reviewed full-text English journals starting from the earliest papers to May 2017. A study population (or part of the study population) of adults older than 65 years (if possible) was included. We especially underscore the use of US by clinicians as an extension of their physical examination or as a practical guide for an immediate intervention.

Determining predictors of mortality among older adults might help identify high-risk patients and enable timely intervention. The aim of the study was to identify which variables predict geriatric outpatient mortality, using routine geriatric assessment tools. We analyzed the data of 1141 patients who were admitted to the geriatric medicine outpatient clinic between 2001 and 2004. Comprehensive geriatric assessment was performed by an interdisciplinary geriatric team. Mortality rate was determined in 2015. The parameters predicting survival were examined. Median age of the patients (415 male, 726 female) was 71.7 years (53–95 years). Mean survival time was 12.2 years (95 % CI; 12–12.4 years). In multivariate analysis, age (OR: 1.16, 95 % CI: 1.09–1.23, p

In Mini-Nutritional Assessment-Short Form (MNA-SF) test, a practical and reliable alternative parameter is still necessary for patients with difficult body mass index evaluation. We aimed to show whether or not handgrip strength may be used instead of body mass index (BMI) in MNA-SF test. MNA-SF test scores, calf circumferences (CC), handgrip strength (HGS), and BMI of 191 patients were evaluated. The first one of calculated MNA-SF tests was with BMI, the second one with CC, and the last one with HGS. Zero point was given if CC was

Background: Sarcopenia is an important problem for older adults, leading to morbidity and mortality; therefore, early detection with a precise method is essential. We aimed to investigate the role of bioelectrical impedance analysis-derived phase angle as a determinant of sarcopenia. Materials and Methods: A cross section of 263 community-dwelling and hospitalized older adults (>65 years) were assessed in terms of sarcopenia with bioelectrical indices and anthropometric measurements. Sarcopenic and nonsarcopenic groups were compared, and significant determinants of sarcopenia were further analyzed with multivariate logistic regression analysis. Results: Forty patients were diagnosed with sarcopenia. The following were significant correlates of sarcopenia: female sex, low weight/height, low body mass index, decreased muscle strength, low calf circumference, low skeletal muscle mass/index, high impedance at 50 kHz, a history of hypertension, worse nutrition status, and low phase angle. Diagnostic parameters with well-known association were omitted, and sex, height, weight, body mass index, creatinine, nutrition status, phase angle, impedance at 50 kHz, and hypertension category were included in regression analysis. The following were independent associated factors with sarcopenia: phase angle (odds ratio [OR]: 0.59, 95% confidence interval [95% CI]: 0.40-0.87, P = .008), body mass index (OR: 0.84, 95% CI: 0.77-0.93, P = .001) impedance at 50 kHz (OR: 1.010, 95% CI: 1.006-1.015, P < .001), and height (OR: 0.93, 95% CI: 0.88-0.97, P = .001). Receiver operating characteristic analysis revealed that the optimal phase angle cutoff value to detect sarcopenia was 4.55o. Conclusions: Bioelectrical phase angle can be useful for diagnosis of sarcopenia.

Nurses and physicians provide health care for a growing number of older people as a result of the rapid increase in the life expectancies of older people. Health professionals' negative attitudes towards older people affect the quality of health care offered to these individuals. The sample for this study included 110 nurses and 57 physicians working in the medical and surgical clinics of a university hospital. A questionnaire form and the Ageism Attitude Scale (AAS) were used to collect the data. A five-point Likert-type format was utilised for the AAS. The AAS total mean score was 80.02 +/- 2.64 for nurses and 83.17 +/- 9.09 for physicians. The difference between these mean scores was statistically significant (p < 0.05). For the AAS sub-dimension 'limiting the life of the older people,' the physicians' score (35.14 +/- 6.22) was significantly higher than the nurses' score (33.22 perpendicular to 3.59). In this study, nurses' and physicians' attitudes, approaches, and considerations were found to be generally positive.

Sarcopenia and sarcopenic obesity (SO) are geriatric syndromes leading to physical disability, poor quality of life and death. The aim of this study was to investigate the prevalence of sarcopenia and SO in nursing homes in Turkey and to define local disparities for diagnosing sarcopenia and SO. This cross-sectional multicenter study was performed in 711 patients in 14 nursing homes. Comprehensive geriatric assessment tests, handgrip strength and calf circumference (CC) measurements were carried out. Sarcopenia was both defined by handgrip strength and CC criteria. According to handgrip strength measurement, 483 (68%) of patients were sarcopenic (male: 72%, female: 63.8%), 228 were non-sarcopenic. The prevalence of SO was 22% (13.7% in men, 30.2% in women). Patients (82.5%) who were diagnosed as sarcopenic by the handgrip strength test were not sarcopenic according to CC sarcopenia criteria. Therefore, we tried to determine the optimal CC value for diagnosing sarcopenia in our population. Both sarcopenia and SO were prevalent among Turkish nursing home elderly residents. Most of the patients with sarcopenia were obese or overweight. We showed that diagnosing sarcopenia with CC measurement underestimated the sarcopenia prevalence assessed by handgrip strength. So we concluded that, although different assessment methods are recommended for the diagnosis of sarcopenia local disparities should be considered.

Immunosuppression-associated Kaposi’s sarcoma (KS) is a rare condition and generally consists of using long-term immunosuppressive therapy. KS seen after using low-dose corticosteroid therapies has been reported two cases before. Herein, we report a third case of KS developed in a geriatric patient using lowdose steroid for polymyalgia rheumatica. 2014 Published by Elsevier Masson SAS. Available online at

Background and aim Malnutrition is related with serious morbidity and mortality in institutionalized older adults. The aim of this study is to determine the frequency of malnutrition in nursing homes and care homes and to identify the factors associated with malnutrition in these settings. Methods This multicenter study was conducted in 14 centers of nursing homes/care homes in three different cities. Total number of 1797 residents aged ≥ 65 years was enrolled. Malnutrition screening was made by Mini Nutritional Assessment Short Form (MNA-SF) and full MNA. Statistical analyses were conducted by SPSS 15.0. Results The median age (min–max) of the study population was 78.0 (65.0–108.0) and 917 (51%) were female. MNA-SF score of the residents was 11 (0-14). According to the MNA-SF 850 (49.3%) residents had normal nutritional status, 654 (38.3%) residents were at malnutrition risk, and 204 (11.9%) had malnutrition. Number of medications, gender, duration of stay in the institution, frequency of family visits, social security status, type of nursing home (government or not), daily life activities (ADL), Geriatric Depression Scale (GDS) and MMSE scores, get up & go test, hypertension, dementia, depression, and Parkinson disease were associated with malnutrition. Regression analyses revealed that get up&go test, GDS, hypertension, and ADL were independently related to malnutrition diagnosed by MNA-SF. Conclusion This study provides important information on the prevalence and associated factors of malnutrition in a large multicentered setting of nursing homes and care homes. It will direct the screening plans and interventions taken in order to detect, prevent, and manage malnutrition in these settings.

Purpose The mini-nutritional assessment (MNA) has been used most frequently for the determination of malnutrition in older adults; however it is not suitable for some hospitalized patients. The aim of this study was to identify the nutritional status of the elderly hospitalized patients by MNA and by other assessment methods including anthropometric measurements, bioelectrical impedance analysis (BIA) and laboratory parameters and to demonstrate the correlation of them with MNA. Patients A total of 100 patients were included in the study. Linear regression analysis was performed to compare the effects of parameters on MNA scores. Results By MNA; 69% of the patients were found to have nutritional risk, 12% were malnourished and 19% were well nourished. Skinfold thicknesses, calf circumference, prealbumin, albumin, C-reactive protein (CRP), glomerular filtration rate (GFR) and some of the BIA parameters including body fat, free fat mass index, extracellular, intracellular and total body water were significantly correlated with MNA score in univariate analysis. On the other hand; only suprailiac skinfold thickness (OR: 0.106, 95%CI: 0.031–0.181, P : 0.006), prealbumin (OR: 0.256, 95%CI: 0.158–0.354, P P : 0.01) were significantly correlated with MNA in multivariate analysis. Conclusions These parameters or their combinations can be used for the evaluation of nutritional status in hospitalized older adults when the MNA cannot be used.

Vitamin D has a well-known critical role in calcium and bone homeostasis. In recent years, there has been an increased interest in the potential regulatory role of vitamin D on metabolic pathways implicated in muscle functions. Evidence coming from epidemiologic studies has demonstrated that poor vitamin D status is associated with worse muscle functions. However, whether vitamin D deficiency and supplementation has a role on sarcopenia is not fully known. This review will focus on current knowledge and emerging data regarding the role of vitamin D in muscle functions and sarcopenia. (C) 2015 Elsevier Masson SAS and European Union Geriatric Medicine Society. All rights reserved.

Sarcopenia is a geriatric syndrome characterized by the presence of low muscle mass and function. Possible mechanisms underlying sarcopenia include oxidative stress and elevation of inflammatory cytokines. The aim of the study was to evaluate the relationship between sarcopenia and biomarkers that may be involved in its pathogenesis and hence early detection. A total of 72 patients (36 sarcopenic and 36 non-sarcopenic) were included in the study. An experienced geriatric team applied comprehensive geriatric assessment to all patients. Anthropometric measures, gait speed and handgrip strength were recorded. Bioelectrical impedance analysis was used to assess skeletal muscle mass. In addition to routine clinical laboratory tests, serum adiponectin, thioredoxin-1 and pentraxin-3 levels were measured. Sarcopenia was defined according to the European Working Group on Sarcopenia in older Adults as the presence of low muscle mass and low muscle function or muscle performance. Sarcopenic patients were more likely to be functionally dependent and had lower scores on comprehensive geriatric assessment tools. Erythrocyte sedimentation rate (ESR) and C-reactive protein levels were significantly higher in the sarcopenic group. There was no significant difference in serum levels of thioredoxin-1 and pentraxin-3. Sarcopenic patients had lower levels of hemoglobin, albumin, total protein, calcium, triglycerides, uric acid and adiponectin (p

The study aimed to investigate the effects of frailty on clinical outcomes of patients in an intensive care unit (ICU). In this prospective study, 122 patients (59 frail, 37 pre-frail and 26 robust) were included. A frailty index (FI) derived from comprehensive geriatric assessment parameters was used for the evaluation. The FI score of ≤0.25 was considered as robust, 0.25–0.40 as pre-frail and >0.40 as frail. The prognostic effects of FI were investigated and FI and APACHE II and SOFA scores, the prognostic scores using in ICU, were compared. Median age of the patients was 71 years old and 50.8 % were male. ICU mortality rate and median length of stay (LOS) were 51.6 % and 8 days (min–max: 1–148), respectively. ICU mortality was higher (69.2, 56.8 and 40.7 %, respectively, p = 0.040) and median overall survival was lower in frail group compared to pre-frail and robust subjects (23, 31 and 140 days, p = 0.013, respectively). Long term mortality over 3 and 6 months in frail patients were 80.8 and 84.6 %, respectively and significantly higher than others. Multivariate analysis showed that LOS in ICU (HR 1.067, 95 % CI 1.021–1.114), SOFA score (HR 1.272, 95 % CI 1.096–1.476) and FI (HR 39.019, 95 % CI 1.235–1232.537) were the independent correlates for ICU mortality (p = 0.004, p = 0.002 and 0.038, respectively). There was a weak but statistically significant positive correlation between APACHE II and FI scores (r = 0.190, p = 0.036). FI may be used as a predictor for the evaluation of elderly patients’ clinical outcomes in ICUs.

Background and aim Ferritin level is decreased in iron deficiency (ID) and increased in inflammation as an acute-phase reacting protein. In the case of inflammation ferritin, level may not decrease even if ID is present. Inflammation is regarded as one of the mechanisms of aging. This subclinical systemic inflammatory state is named as “inflammaging”. The aim of this study is to assess whether serum ferritin levels could indicate aging-associated inflammation rather than ID in older adults. Methods Consecutive 1310 patients admitted to the geriatric medicine outpatient clinic were enrolled. The clinical conditions, which could alter acute-phase reactants, were excluded. ID diagnosis was made by transferrin saturation ( Results Mean age was 71.8 ± 6.9 years and 827 (63.1%) were female. Ferritin levels were significantly higher in patients with subclinical inflammatory state and significantly lower in patients with ID. The interrelationships of the ferritin with acute-phase reactants were stronger than its relationship with the ID. Conclusion The results of this study suggested that the ferritin level can increase with aging as a part of the ongoing asymptomatic chronic systemic inflammatory state called inflammaging. Inflammaging can result with increased ferritin levels, even if there is ID. Normal or elevated levels of ferritin in the geriatric population should not exclude ID in clinical practice.

Cardiovascular disease (CVD) and OP are common age-related conditions. In both cross-sectional and longitudinal epidemiologic studies, low bone mass has been related to increased frequency of CVD. But available data in geriatric population is limited. In this study we aimed to seek the possible relationship between CAD and low bone mineral density (BMD) in a large number of geriatric patients. A total of 2235 patients aged 65 years or more were included in this cross-sectional study. All patients underwent a complete geriatric assessment and evaluated for CAD and cardiovascular risk factors. BMD was measured by dual-energy X-ray absorptiometry at the lumbar spine (L1-L4) and femoral neck. BMD results were classified into three groups; normal (T-score: ≥-1.0×S.D.), osteopenia (T-score between -1.0 and -2.5×S.D.), and OP (T-score: ≤-2.5×S.D.). CAD was present in 397 (29.7%) of 1335 patients with OP, in 199 (27.4%) of 726 patients with osteopenia and in 34 (19.5%) of 174 patients with normal BMD. Multivariate regression analysis revealed that presence of OP or osteopenia increased the prevalence of CAD as an independent correlate (OR=1.643; 95% CI=1.068-2.528, p=0.030). This study highlights the need for careful evaluation of elderly patients with low BMD for possible CAD.

Background Autonomic nervous system disturbance and cardiovascular disorders may be underestimated causes of falls. Heart rate turbulence (HRT), heart rate variability (HRV) and QT dynamicity parameters are noninvasive cardiac autonomic activity markers. The aim of this study was to evaluate autonomic cardiovascular markers in falling older adults. Methods This was a case-control study conducted at a geriatric medicine outpatient clinic of a university hospital. Study group consisted of 33 older adults who had falls in the last 12months and the control group included 31 subjects who had never experienced falls. The patients in the study group were examined with 24-hour Holter electrocardiogram (ECG) and carotid sinus massage was done under monitorization. The 24-hour Holter ECG data were recorded and assessed with the ELATEC software. HRV, QT dynamicity and HRT parameters were analysed. Results Thirty-three faller and 31 non-faller patients were examined in this study. Age and gender were similar between groups. All patients and control subjects had normal ejection fraction. Carotid sinus massage was done to the patients in the study group and three of 33 were positive (9.09%). There was no significant difference in HRV and QT dynamicity parameters between groups. Both HRT onset (2.51±1.48 vs. 7.29±3.28 P P =0.031) were significantly different between the groups. Conclusion Elderly subjects with recent falls have significantly worse HRT parameters than matched non-falling counterparts. Blunted baroreflex sensitivity and impaired cardiac autonomic function can be an important reason for falls in the geriatric age group.

Background/Aim: Dementia is one of the most common health problems in the world. Alzheimer’s disease (AD) is the most common form of dementia. The relation between blood pressure (BP) and dementia has been the subject of numerous epidemiological studies, and midlife hypertension (HT) is a risk factor for AD. The association between BP and risk of dementia is lower in the older population. The aim of this study was to examine the association between the prevalence of HT and AD in elderly individuals. Methods: In this cross-sectional study, 193 patients with AD and 1,860 patients with normal cognitive function were evaluated. Results: The prevalence of HT was lower in the AD group (60.6 vs. 70.5%; p = 0.005). In multivariate analysis, AD was found to be negatively correlated with HT (OR = 0.649; 95% CI 0.461–0.916). Conclusion: The prevalence of HT was lower in patients with AD compared to subjects without AD. Physicians who deal with AD patients must keep in mind that the need for antihypertensive medication may decline during the dementia process.

There is growing consensus in the literature that inflammation plays a significant role in the pathophysiology of Alzheimer's disease (AD). The blood neutrophil-lymphocyte ratio (NLR) is a new, inexpensive and easily applicable marker of inflammation. The aim of this study was to investigate the association between NLR, as an inflammatory biomarker, and AD.241 AD patients and 175 patients with normal cognitive function were evaluated in this study.The mean ± SD NLR of AD patients was significantly higher than that of patients with normal cognitive function (3.21 ± 1.35 vs. 2.07 ± 0.74, p0.001, respectively). Receiver operating characteristic curve analysis suggested that the optimum NLR cutoff point for AD was 2.48 with 69.29% sensitivity, 79.43% specificity, 82.30% positive predictive values and 65.30% negative predictive values. Logistic regression analysis showed that elevated NLR (OR: 4.774, 95% CI: 2.821-8.076, p0.001) was an independent variable for predicting AD.Elderly people with AD have higher NLR than healthy controls. Elevated NLR levels are usually considered as an inflammatory marker. The results of this study suggested that inflammation plays a role in the pathogenesis of AD.

Alzheimer disease (AD) is the most common progressive neurodegenerative disorder causing increased morbidity and mortality. It is characterized by accumulation of amyloid-β in neurons. As there is no known definitive treatment of this disorder, studies trying to determine its exact pathogenetic pathways and target therapies for these specific pathways are being rapidly conducted. Autophagy is one of the areas of interest in studies on the pathogenesis of AD. It is a process of self-digestion that is thought to be a response to stressors and allows cells to adapt to environmental changes. There is accumulating evidence showing an association between autophagy and some disorders like cancer, infectious disease, and, in particular, neurodegenerative disorders. Growing attention has been focused on impaired autophagy in neurodegenerative disorders including AD, resulting in buildup of toxic molecules because of inappropriate activation of proteases or defective proteolysis. The question of whether autophagic response may be precisely modulated to prevent or treat neurodegenerative disorders like AD is still unanswered. In the future, it is thought that the autophagic process may be the one of the cornerstones of the treatment of AD. In this review, we summarize the knowledge of autophagy in the pathogenesis of AD in light of the current literature.

Dementia is an inevitable disease of aging, leading not only to diminished cognitive ability but also behavioral changes, malnutrition, pressure sores, and infections. Acknowledging common problems and their solutions is essential for any health service worker who deals with demented geriatric patients.

Summary Background & aims Older adults are poorly assessed for malnutrition risk although malnutrition is not an uncommon problem in this population. The aim of this study was to determine the malnutrition risk and its correlates in geriatric outpatients. Method The study was performed in 2327 patients ≥65 years old who were admitted to our Geriatric Medicine outpatient clinic. Together with comprehensive geriatric assessment, nutritional assessment with short version of mini nutritional assessment test (MNA-SF) was performed. MNA-SF score ≤11 was determined as malnutrition risk. Results Mean age of patients was 72.14 ± 6.11 and 1479 (63.6%) were female. Mean MNA-SF score was 12.31 ± 2.18. The number of patients with MNA-SF score ≤11 was 651 (28%). Depression, haematocrit, plasma fasting glucose, albumin, erythrocyte sedimentation rate, instrumental activities of daily living scores and bone mineral density measured from total femur were found to be significantly associated with malnutrition risk. Conclusion In this study malnutrition risk was detected in 651 (28%) patients. This ratio was similar to the literature. In older adults malnutrition risk is found to be increased due to majority of chronic illnesses and physical dependency. In conclusion, nutritional assessment should be a part of comprehensive geriatric assessment.

Background: Gamma glutamyltransferase (GGT) plays a role in cellular glutathione uptake, which is an important element of antioxidant mechanisms. An increase in serum GGT is thought to be an early and sensitive marker of oxidative stress. Oxidative stress has a role in the pathogenesis of Alzheimer's disease (AD). The aim of this study was to investigate the GGT levels in AD.Method: In this cross-sectional study, 132 patients with AD (mean age: 74.1 ± 7.4, female 62.9%) and 158 age- and gender-matched normal controls (mean age: 74.5 ± 6.3, female 67.1%) were evaluated. For cognitive assessment, MMSE and clock drawing tests were performed; DSM-IV and NINCDS-ADRDA criteria were used. Serum GGT, aspartate aminotransferase, alanine aminotransferase and alkaline phosphatase concentrations were determined.Results: Median (min-max) GGT levels were 18 (9–70) in AD group and 17 (5–32) in normal controls. Mann-Whitney U test showed that GGT levels were significantly higher in AD patients (p = 0.012). Linear regression analysis revealed AD was an independent correlate of elevated GGT levels. Hypertension, diabetes mellitus, total cholesterol, and low density lipoprotein cholesterol were not associated with GGT levels.Conclusion: GGT levels were increased significantly in AD patients. To evaluate the role of GGT as a marker of oxidative stress in AD, further studies are needed.

The most efficient strategy for combating Alzheimer's disease (AD) is to prevent the onset of clinically significant symptoms. Determining the clinical characteristics, risk factors, and indices of cognitive reserve would help in achieving this goal. The aim of this study was to determine the risk factors for AD and vascular dementia (VD) in the elderly and to highlight the importance of risk factor modification in the early diagnosis. Consecutive 1436 patients (mean age = 72.7 ± 6.9 years, 34.2% male) were enrolled in the study. After a comprehensive geriatric and cognitive assessment, patients were grouped as AD group (n = 203), VD group (n = 73) and normal cognitive status (NCS) group (n = 1160). Thirty-three possibly related factors including demographic characteristics, co-existing diseases and laboratory parameters were examined. The results revealed that female sex, advanced age, depression, and intake of vitamin supplements were independent related factors for AD; whereas depression and low-density lipoprotein-cholesterol (LDL-C) were independent related factors for VD. For every geriatric patient admitted for any reason, cognitive assessment should be performed, risk factors should be determined and the patients at high risk should be followed up carefully.

OBJECTIVES: To compare endothelial function of people with Alzheimer's disease (AD) with that of people without. DESIGN: Case-control study. SETTING: Geriatric medicine outpatient clinic of a university hospital. PARTICIPANTS: Twenty-five patients with AD who were free of vascular risk factors and 24 healthy elderly controls were enrolled. Exclusion criteria were diabetes mellitus, hypertension, dyslipidemia, evident stroke, smoking, documented coronary artery disease, history of myocardial infarction, heart failure, acute or chronic infection, malignancy, peripheral artery disease, renal disease, rheumatologic diseases, alcohol abuse, and certain drugs that may affect endothelial function. Both groups underwent comprehensive geriatric assessment and neuropsychiatric assessment. MEASUREMENTS: Endothelial function was evaluated according to flow-mediated dilation (FMD) from the brachial artery. RESULTS: Mean age ± standard deviation was 78 ± 5.9 in the group with AD (11 female and 14 male) and 72.1 ± 5.8 in the control group (9 female and 11 male). Multiple linear regression analysis revealed that FMD was significantly lower in patients with AD (median 3.45, range 0–7) than controls (median 8.41, range 1–14) (P < .001), independent of age. It was also found that FMD values were inversely correlated with the stage of the disease as determined according to the Clinical Dementia Rating scale (r=−0.603, P < .001). CONCLUSION: Endothelial function is impaired in patients with AD. Endothelial function was worse in patients with severe AD. These findings provide evidence that vascular factors have a role in the pathogenesis of AD.

Aim To assess the appropriateness of utilization of beds in the internal medicine department of a university hospital. Methods The appropriateness of hospital stay was evaluated using the Appropriateness Evaluation Protocol. A random sample of 402 days of stay was assessed. Results One hundred and thirty-nine days of stay (34.6%) were classified as inappropriate. The inappropriate stays were mostly secondary to hospital-related factors. The two major factors for inappropriate stays were ‘inappropriate timing/delay in diagnostic procedures/consultations’ (27%) and ‘delay in obtaining test results’ (27%). None of the factors including age, gender, residence and inpatient period was significantly related to inappropriate stay in univariate analysis. Conclusion This study indicated that a significant portion of stays were inappropriate. Efforts to decrease particularly hospital-related factors associated with inappropriate stay are needed.

Background: Strontium ranelate offers significant clinical benefits in terms of efficacy, tolerability, and ease of administration in the treatment of postmenopausal osteoporosis. However, there are some data revealing an association between strontium ranelate treatment and increased incidence of venous thromboembolism (VTE), suggesting possible adverse prothrombotic effects of the drug. Objective: To assess the effect of strontium ranelate treatment on primary hemostasis, secondary hemostasis, and the natural anticoagulant defense system, together with prothrombotic markers, in elderly women with osteoporosis. Methods: This study was designed in a prospective manner. Thirty-five elderly women diagnosed with osteoporosis were included. During a 2 month treatment period, participants received strontium ranelate 2 g. Platelet Function Analyzer-100 (PFA-100) in vitro bleeding time was performed to depict primary hemostasis. Secondary hemostatic parameters including prothrombin time, international normalized ratio, activated partial thromboplastin time, anti-cardiolipine immunoglobulin (Ig) M and IgG, antiphospholipid IgM and IgG, protein C, protein S, anti-thrombin III, lupus anticoagulant, fibrinogen, thrombin, activated protein C resistance, and plasma levels of d-dimer were assessed. These parameters were tested before and after 2 month treatment with strontium ranelate. Results: Mean ± SD age of the patients was 72.82 ± 5.69 years. After 60 days of treatment, there was no statistically significant prolongation in PFA-100 in vitro bleeding time and no statistically significant change in the critical hemostatic parameters in patients receiving strontium ranelate that led to discontinuation of the treatment. None of the subjects developed clinical VTE during the 2 month period of strontium ranelate treatment. Conclusions: The hemostatic safety of strontium ranelate in the elderly population with osteoporosis was shown over 2 months of treatment; however, its long-term hemostatic safety should be evaluated further.

Cancer prevalance and incidence is increasing with aging of populations and age is a critical factor in decision-making for anti-cancer treatment. However it is believed that chronological age is not enough to guide management in elderly cancer patients. Multidisciplinary evaluation and comprehensive geriatric assessment has gained importance regarding the treatment selection especially for definitive anti-cancer therapy recently. We here aimed to analyse the effect of the comprehensive geriatric assessment parameters on radiotherapy toxicity and tolerability in a series of geriatric cancer patients in Turkey.

The phenomenon of falls is not well studied in developing world. However, being aware of possible correlates for falls specific to different populations and trying to eliminate these factors is very important to prevent falls. This study investigated occurrence and correlates of falls among elderly in a developing country, Turkey. A total of 2322 patients aged 65 years and over presented to outpatient clinics of a reference hospital were included in this cross-sectional study. All patients had a complete comprehensive geriatric assessment and questioned for fall history. Correlates for falls were analyzed by using logistic regression. The mean age of participants was 71.8 years; 63.5% were female and 28.5% were found to have fallen within one year. Female sex, visual problems, auditory problems, use of mobility aids, mobility problems and depression were the only independent correlates for falls. Although the cross-sectional design of this study may not prove the causal role of the risk indicators, the size of the study group as well as the large number of possible correlates examined enriches the study. The results from this cross-sectional study form a basis for further prospective study on falls in the Turkish elderly population.

Summary Objectives To investigate fever of unknown origin (FUO) in 97 patients and compare geriatric and adult population. Methods We investigated 97 (22 elderly) patients with FUO using the criteria of Petersdorf and Beeson [Medicine 40 (1961) 1] hospitalized between January 1990 and May 2005 at Hacettepe University Hospital. Results Infectious diseases were the most common cause in the adult (33.3%) and the elderly (45.5%) patients both. Neoplasms were seen in 18.7; 4.5% and collagen vascular diseases were diagnosed in 9.3; 4.5% of the adults and the elderly respectively. Tuberculosis accounted for 60% of all the infectious causes and empirical anti-tuberculous treatment served as a diagnostic method in 43% of the cases with tuberculosis. Lymphadenopathy was more common among the adults with FUO. A diagnosis could be reached in all the elderly patients with a very high erythrocyte sedimentation rate (ESR>100mm/h). At the end of the hospitalization, 14.7% (11/75) of the adult patients and 13.6% (3/22) of the elderly patients died. Conclusion Geriatric patients with FUO usually have characteristics similar to the adult patients with respect to the hospitalization time, diagnosis, and inpatient mortality. Lymphoid organ hyperplasia might be expected less frequently and very high ESR might be a more reliable indicator of systemic disease in the elderly. Empirical anti-tuberculous treatment plays an important diagnostic role in the developing countries with a higher prevalence of tuberculosis.

Objective The number of older people is growing fast in Turkey. In this context, internal medicine residents and specialists contact older people more frequently. Thus, healthcare providers’ knowledge and attitudes toward older people is becoming more important. Studies that specifically investigate internal medicine residents’ attitudes toward the elderly are scarce. We aimed to investigate the attitudes of internal medicine residents toward older people. Methods This cross-sectional multicenter study was undertaken in the internal medicine clinics of six university state hospitals that provide education in geriatric care. All internal medicine residents working in these hospitals were invited to participate in this questionnaire study between March 2013 and December 2013. We recorded the participants’ age, sex, duration of internal medicine residency, existence of relatives older than 65 years, history of geriatrics course in medical school, geriatrics rotation in internal medicine residency, and nursing home visits. Results A total of 274 (82.3%) of the residents participated in this study, and 83.6% of them had positive attitudes toward older people. A geriatrics rotation during internal medicine residency was the only independent factor associated with positive attitudes toward the elderly in this multivariate analysis. A geriatrics course during medical school was associated with positive attitudes in the univariate analysis, but only tended to be so in the multivariate analysis. Conclusion Geriatrics rotation during internal medicine residency was independently associated with positive attitudes toward older people. Generalization of geriatrics education in developing countries may translate into a better understanding and improved care for older patients.

This study aimed to determine the reliability and validity of the Turkish version of Disability Assessment for Dementia (DAD) scale in the Turkish elderly population with Alzheimer disease (AD). The DAD scale was administered to the primary caregivers of 157 patients (age 77.7 ± 6.8 years) with AD. The Turkish version of the DAD scale showed high internal consistency (Cronbach α = .942), excellent test–retest, and interrater reliability (intraclass correlation coefficient [ICC] = 0.996 and ICC = 0.994, respectively). The DAD scale was significantly correlated with activities of daily living (ADL; Modified Older Americans Research Survey ADL) and instrumental activities of daily living (IADL; Lawton and Brody IADL) scales ( r = .89, P < .001 and r = .90, P < .001). Disability Assessment for Dementia had a high negative correlation with the Global Deterioration Scale (GDS; r = −.880, P < .001). Post hoc comparisons with Tukey test showed significant differences in the mean DAD scores in different GDS stages. Construct validity was estimated using total score correlation analyses between the standardized Mini-Mental State Examination (MMSE) and the DAD scale. Results revealed high and significant correlation between MMSE score and DAD scale ( r = .812, P < .001). The results of multivariate analysis showed that DAD score was not correlated with gender, education, and age. The DAD total score was affected mostly by GDS, MMSE, and duration of the disease. Turkish version of the DAD scale was found to be a reliable and valid instrument to assess functional disability in Turkish elderly patients with AD. This scale assists caregivers and physicians to decide for proper interventions.