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BACKGROUND/OBJECTIVES Atrial fibrillation (AF) subtypes may carry different cardiovascular risk profiles, but information on their frequency from population-based studies is lacking. We estimated prevalence of AF subtypes in a representative sample of the Italian older population, projecting figures for Italy and the European Union. DESIGN Cross-sectional study. SETTING Three primary care practices in northern, central, and southern Italy. PARTICIPANTS All individuals aged 65 years or older, for a total sample of 6,016 subjects. Excluding 235 noneligible, participation was 78.3%, which left 4,528 participants. MEASUREMENTS A double systematic and opportunistic screening procedure identified possible AF cases, followed by clinical and electrocardiogram confirmation. Patients were categorized with paroxysmal, persistent, or permanent AF. Prevalence was calculated by sex and 5-year age groups. Prevalence figures were applied to population projections for all 28 European Union states to estimate AF subtypes expected in future decades. RESULTS In the 4,528 participants (mean age = 74.5 ± 6.8 years; 47.2% men), 331 AF cases were identified: 140 (42.3%) paroxysmal, 77 (23.3%) persistent, and 114 (34.4%) permanent. Prevalence was 3.1% (95% confidence interval (CI) = 2.6%-3.6%) for paroxysmal, 1.7% (95% CI = 1.4%-2.1%) for persistent, and 2.5% (95% CI = 2.1%-3.0%) for permanent AF. Italian older persons having AF in 2016 were estimated at approximately 449,000 for paroxysmal, approximately 240,000 for persistent, and approximately 391,000 for permanent AF, projected to increase in 2060 to approximately 785,000, approximately 358,000, and approximately 748,000, respectively. European Union older persons having AF in 2016 were estimated at approximately 3,185,000 for paroxysmal, approximately 1,722,000 for persistent, and approximately 2,710,000 for permanent AF, projected to increase in 2060 to approximately 5,989,000, approximately 2,833,000, and approximately 5,579,000, respectively. CONCLUSION We provided first projections of AF subtypes for Italy and Europe. The worse cardiovascular risk profile of persistent and permanent forms indicates an increased burden in future decades.

Benefits of oral anticoagulants (OAC) in atrial fibrillation (AF) patients with moderate-to-high risk of stroke are independent of AF pattern. We evaluated whether AF clinical subtype influenced OAC use in a representative sample of the Italian older population.A cross-sectional examination of all subjects aged 65 + years from three general practices in northern, central, and southern Italy started in 2016. A double-screening procedure was followed by clinical and ECG confirmation. Patients were categorized as having paroxysmal, persistent, or permanent AF. OAC use was evaluated in confirmed AF patients.The sample included 6016 subjects. Excluding 235 non-eligible, participation was 78.3%, which left 4528 participants (mean age 74.5 ± 6.8 years, 47.2% men). Overall, 319 AF cases were identified: 43.0% had paroxysmal, 21.3% persistent, and 35.7% permanent AF. Frequency of OAC therapy was 91.2% in permanent, 85.3% in persistent, and only 43.0% in paroxysmal AF (P 0.001). In multivariate analysis, controlled for baseline variables and risk scales, persistent and permanent AF were associated with a significant increase in the likelihood of receiving OAC compared with paroxysmal AF (P 0.001). This was confirmed for permanent AF also in multivariate analyses considering separately vitamin K antagonists or direct-acting oral anticoagulants (OR, 4.37, 95% CI, 2.43-7.85; and 1.92, 95% CI, 1.07-3.42, respectively) and for persistent AF and direct-acting oral anticoagulants (OR, 4.33, 95% CI, 2.30-8.15).In a population-based survey, AF pattern was an independent predictor of OAC treatment. Paroxysmal AF is still perceived as carrying a lower risk of vascular events.

The approach to reperfusion therapies in stroke patients is rapidly evolving, but there is still no explanation why a substantial proportion of patients have a poor clinical prognosis despite successful flow restoration. This issue of futile recanalization is explained here by three clinical cases, which, despite complete recanalization, have very different outcomes. Preclinical research is particularly suited to characterize the highly dynamic changes in acute ischemic stroke and identify potential treatment targets useful for clinical translation. This review surveys the efforts taken so far to achieve mouse models capable of investigating the neurovascular underpinnings of futile recanalization. We highlight the translational potential of targeting tissue reperfusion in fully recanalized mouse models and of investigating the underlying pathophysiological mechanisms from subcellular to tissue scale. We suggest that stroke preclinical research should increasingly drive forward a continuous and circular dialogue with clinical research. When the preclinical and the clinical stroke research are consistent, translational success will follow.

Aims To estimate prevalence of atrial fibrillation (AF) in a representative sample of the Italian elderly population, projecting figures for Italy and the European Union. Methods and results A cross-sectional examination of all subjects aged 65+ years from three general practices in Northern, Central, and Southern Italy started in 2016. Participants were administered a systematic and an opportunistic screening, followed by clinical and electrocardiogram confirmation. The study sample included 6016 subjects. Excluding 235 non-eligible, among the remaining 5781 participation was 78.3%, which left 4528 participants (mean age 74.5 ± 6.8 years, 47.2% men). Prevalence of AF was 7.3% [95% confidence intervals (CI) 6.6–8.1], higher in men and with advancing age (6.6% from systematic plus 0.7% from opportunistic screening). Using prevalence figures, Italian elderly having AF in 2016 were estimated at ∼1 081 000 (95% CI 786 000–1 482 000). Considering stable prevalence, this number will increase by 75% to ∼1 892 000 in 2060 (95% CI 1 378 000–2 579 000). European Union elderly having AF in 2016 were estimated at ∼7 617 000 (95% CI 5 530 000–10 460 000), increasing by 89% to ∼14 401 000 in 2060 (95% CI 10 489 000–19 647 000). In 2016, subjects aged 80+ years represented 53.5% of cases in Italy and 51.2% in the European Union; in 2060, 69.6% and 65.2%, respectively. Conclusions Our findings indicate a high burden of AF in coming decades, especially among the oldest-old, who carry the higher AF-related risk of stroke and medical complications.

Introduction Frailty is a critical intermediate status of the aging process including physical, cognitive, and psychosocial domains/phenotypes. We operationalized a new biopsychosocial frailty (BF) construct, estimating its impact on the risk of incident dementia and its subtypes. Methods In 2171 older individuals from the population-based Italian Longitudinal Study on Aging (ILSA), we identified by latent class procedures the BF construct as the physical frail status plus at least one of the two items of the 30-item Geriatric Depression Scale impaired (items 3/10). Results Over a 3.5-year follow-up, participants with BF showed an increased risk of overall dementia (hazard ratio [HR]: 2.16, 95% confidence interval [CI]:1.07-4.37), particularly vascular dementia (VaD) (HR: 3.21, 95% CI: 1.05-9.75). Similarly, over a 7-year follow-up, an increased risk of overall dementia (HR: 1.84, 95% CI: 1.06-3.20), particularly VaD (HR: 2.53, 95% CI: 1.08-5.91), was also observed. Discussion In a large cohort of Italian older individuals without cognitive impairment at baseline, a BF model was a short- and long-term predictor of overall dementia, particularly VaD.

Background Informing health systems and monitoring hospital performances using administrative data sets, mainly hospital discharge data coded according to International-Classification-Diseases-9edition-Clinical-Modifiers (ICD9-CM), is now commonplace in several countries, but the reliability of diagnostic coding of acute ischemic stroke in the routine practice is uncertain. This study aimed at estimating accuracy of ICD9-CM codes for the identification of acute ischemic stroke and the use of thrombolysis treatment comparing hospital discharge data with medical record review in all the six hospitals of the Florence Area, Italy, through 2015. Methods We reviewed the medical records of all the 3915 potential acute stroke events during 2015 across the six hospitals of the Florence Area, Italy. We then estimated sensitivity and Positive Predictive Value of ICD9-CM code-groups 433*1, 434*1 and thrombolysis code 99.10 against medical record review with clinical adjudication. For each false-positive case we obtained the actual diagnosis. For each false-negative case we obtained the primary and secondary ICD9-CM diagnoses. Results The medical record review identified 1273 acute ischemic stroke events. The hospital discharge records identified 898 among those (true-positive cases),but missed 375 events (false-negative cases), and identified 104 events that were not eventually confirmed as acute ischemic events (false-positive cases). Code-group specific Positive Predictive Value was 85.7% (95%CI,74.6–93.3) for 433*1 and 89.9% (95%CI, 87.8–91.7) for 434*1 codes. Thrombolysis treatment, as identified by ICD9-CM code 99.10, was only documented in 6.0% of acute ischemic stroke events, but was 13.6% in medical record review. Conclusions Hospital discharge data were found to be fairly specific but insensitive in the reporting of acute ischemic stroke and thrombolysis, providing misleading indications about both quantity and quality of acute ischemic stroke hospital care. Efforts to improve coding accuracy should precede the use of hospital discharge data to measure hospital performances in acute ischemic stroke care.

Objectives Cognitive frailty, a condition describing the simultaneous presence of physical frailty and mild cognitive impairment, has been recently defined by an international consensus group. We estimated the predictive role of a “reversible” cognitive frailty model on incident dementia, its subtypes, and all-cause mortality in nondemented older individuals. We verified if vascular risk factors or depressive symptoms could modify this predictive role. Design Longitudinal population-based study with 3.5- and 7-year of median follow-up. Setting Eight Italian municipalities included in the Italian Longitudinal Study on Aging. Participants In 2150 older individuals from the Italian Longitudinal Study on Aging, we operationalized reversible cognitive frailty with the presence of physical frailty and pre-mild cognitive impairment subjective cognitive decline, diagnosed with a self-report measure based on item 14 of the Geriatric Depression Scale. Measurements Incidence of dementia, its subtypes, and all-cause mortality. Results Over a 3.5-year follow-up, participants with reversible cognitive frailty showed an increased risk of overall dementia [hazard ratio (HR) 2.30, 95% confidence interval (CI) 1.02–5.18], particularly vascular dementia (VaD), and all-cause mortality (HR 1.74, 95% CI 1.07–2.83). Over a 7-year follow-up, participants with reversible cognitive frailty showed an increased risk of overall dementia (HR 2.12, 95% CI 1.12–4.03), particularly VaD, and all-cause mortality (HR 1.39, 95% CI 1.03–2.00). Vascular risk factors and depressive symptoms did not have any effect modifier on the relationship between reversible cognitive frailty and incident dementia and all-cause mortality. Conclusions A model of reversible cognitive frailty was a short- and long-term predictor of all-cause mortality and overall dementia, particularly VaD. The absence of vascular risk factors and depressive symptoms did not modify the predictive role of reversible cognitive frailty on these outcomes.

Objective Cognitive frailty is a condition recently defined by operationalized criteria describing the simultaneous presence of physical frailty and mild cognitive impairment (MCI). Two subtypes for this clinical construct have been proposed: "potentially reversible" cognitive frailty (physical frailty plus MCI) and "reversible" cognitive frailty (physical frailty plus pre-MCI subjective cognitive decline). Here the prevalence of a potentially reversible cognitive frailty model was estimated. It was also evaluated if introducing a diagnosis of MCI in older subjects with physical frailty could have an additive role on the risk of dementia, disability, and all-cause mortality in comparison with frailty state or MCI condition alone, with analyses separately performed for inflammatory state. Methods In 2,373 individuals from the population-based Italian Longitudinal Study on Aging with a 3.5-year-follow-up, we operationally categorized older individuals without dementia into four groups: non-frail/non-MCI, non-frail/MCI, frail/non-MCI, and frail/MCI. Results The prevalence of potentially reversible cognitive frailty was 1%, increasing with age and more represented in women than in men, and all groups were associated with significant increased incident rate ratios of dementia, disability, and mortality. A significant difference in rates of disability has been found between the MCI and non-MCI groups (contrasts of adjusted predictions: 0.461; 95% confidence interval: 0.187–0.735) in frail individuals with high inflammatory states (fibrinogen >339 mg/dL). Conclusion In older individuals without dementia and with elevated inflammation, a potentially reversible cognitive frailty model could have a significant additional predictive effect on the risk of disability than the single conditions of frailty or MCI.

Access to effective acute stroke services is a crucial factor to reduce stroke-related death and disability, but is limited in different parts of Italy. Our study addresses this inequality across the Italian regions by examining the regional legislations issued to adopt and implement the State-Regional Council agreement 03/02/2005 as to the acute stroke management. All decrees and resolutions as to acute stroke were collected from each region and examined by the means of a check list including quantitative and qualitative characteristics, selected in accordance with the recommendations from the State-Regional Council document. Each completed check list was then sent to each regional reference person, who filled in the section on the implementation of the indications and compliance, with the collaboration of stroke specialists if necessary. The study was carried out from November 2009 to September 2010. The documents and information were collected from 19 regions. Our survey revealed disparities both in terms of number of decrees and resolutions and of topics covered by the regional legislations about stroke care. Most legislations lacked practical and economical details. This feedback from national and regional stroke regulations revealed a need of more concrete indications. Involvement of various stakeholders (legislators, consumers, providers) might possibly ensure that policies are actually adopted, implemented and maintained. Although considerable challenges are present to the development of standard and optimal stroke care more widely across Italian regions, the potential gains from such developments are substantial.

Background: The use of emergency services with prehospital stroke assessment and early notification to the treatment hospital (stroke code) is a crucial determinant of delay time for acute stroke treatment. We reviewed and summarized the literature on prehospital stroke code system implementation. Methods: Two databases were explored (last update June 20, 2011) with 3 key words (stroke code, stroke prehospital management and stroke prehospital services). Inclusion criteria were: randomized and quasirandomized controlled trials, cohort and case-control studies, and hospital- and emergency-based registers, with no year or language restrictions. We examined the reference lists of all included articles. All potentially relevant reports and abstracts were transcribed into a specifically designed data abstraction form. Results: Only 19 of the 680 studies which were initially retrieved, published from 1999 to 2011, fulfilled our inclusion criteria. One clinical trial was identified. Large differences in stroke code procedures and study designs within and across countries prohibited the pooling of the data. Most studies were carried out in urban areas. Assuming the rate of tissue-plasminogen activator treatment as the performance measure, most studies report a significant increase in the rate of treatment (increase between 3.2 and 16%) with only 1 study not reporting any increase. Conclusions: Despite its limitations, this review suggests that the use of prehospital stroke code is an important intervention to improve the accessibility of the benefits of thrombolysis, especially when implemented together with educational campaigns to optimize the awareness and behavior of patients and bystanders.

The authors investigated the relationship of metabolic syndrome (MetS) and its individual components with incident dementia in a prospective population-based study with a 3.5-year follow-up.A total of 2097 participants from a sample of 5632 subjects (65-84 years old) from the Italian Longitudinal Study on Ageing were evaluated. MetS was defined according to the Third Adults Treatment Panel of the National Cholesterol Education Program criteria. Dementia, Alzheimer disease (AD) and vascular dementia (VaD) were classified using current published criteria.MetS subjects (N=918) compared with those without MetS (N=1179) had an increased risk for VaD (1.63% vs 0.85%, adjusted hazard ratio (HR) 3.71, 95% CI 1.40 to 9.83). After excluding 338 subjects with baseline undernutrition, MetS subjects compared with those without MetS had an elevated risk of VaD (adjusted HR, 3.82; 95% CI 1.32 to 11.06). Moreover, those with MetS and high inflammation had a still further higher risk of VaD (multivariate adjusted HR, 9.55; 95% CI 1.17 to 78.17) compared with those without MetS and high inflammation. On the other hand, those with MetS and low inflammation compared with those without MetS and low inflammation did not exhibit a significant increased risk of VaD (adjusted HR, 3.31, 95% CI 0.91 to 12.14). Finally, a synergistic MetS effect versus its individual component effects was verified on the risk of VaD.In our population, MetS subjects had an elevated risk of VaD that increased after excluding patients with baseline undernutrition and selecting MetS subjects with high inflammation.

Information on subcortical ischaemic changes (SIC) in young hypertensive patients is scarce. We evaluated the frequency of SIC at magnetic resonance imaging (MRI), the possible effect on cognition of these patients, and the role of plasma markers known as indicators of endothelial and haemostatic activation. Inclusion criteria were age

Cognitive decline, particularly when executive functions are compromised, may worsen motor performance (MP) decline in the elderly population. We investigated whether a global test, a memory test, and an attention test predicted MP decline in older community-dwellers with normal baseline MP participating in the Italian Longitudinal Study on Aging (ILSA).One thousand fifty-two ILSA participants (71.2 +/- 4.8 years old, mean +/- standard deviation [SD], 67% men), with normal baseline MP were reassessed after 3 years using the same MP battery. Participants whose MP score reduction from baseline to follow-up was75 percentile were considered to be MP decliners. Global cognition, memory, and attention were assessed using the Mini-Mental State Examination (MMSE), the Babcock Story Recall Test (BSRT), and the Digit Cancellation Test (DCT), respectively. The baseline score on each test was examined as a potential predictor of decline in global MP or in single motor tasks.Baseline scores on the three cognitive tests were worse among the 166 MP decliners, compared with nondecliners. Participants in the lowest quartile of DCT had a2-fold higher adjusted risk of declining than did participants in the highest quartile (odds ratio = 2.47, 95% confidence interval, 1.29-4.74). Conversely, MMSE and BSRT scores no longer predicted MP decline after adjustment. Impaired attention strongly predicted the decline in attention-demanding tasks (tandem walking), but also affected routine tasks (walking).Impairment in a test measuring attention predicts MP decline among older community-dwellers with normal baseline MP. This finding is consistent with the hypothesis that attentional and executive dysfunction is a major determinant of mobility disability in elderly persons.

Objectives: To estimate prevalence and incidence of distal symmetric neuropathies (DSN) in the Italian elderly, and to evaluate the accuracy of our procedure to screen for DSN. Methods: In eight Italian municipalities, a population-based sample was directly evaluated both at baseline (1992) and after a 3-year follow-up. Cohort members who had died were studied. DSN diagnosis and subtyping were made according to specified diagnostic criteria. Results: Our screening procedure proved accurate (sensitivity 94.7%, specificity 70%, positive predictive value 18.9%), and provided an adjusted prevalence of 7.0 (95% CI, 6.9 to 7.0). Women outnumber men both in the oldest age groups and as a whole. Rates increase with increasing age in both genders. Among the 2,845 individuals re-screened at the follow-up and the 221 deceased subjects with reliable information, we identified 100 incident cases of DSN. Adjusted annual incidence rate (per 1,000 person-years) in the population 65 to 84 years of age is 7.9 (95% CI, 6.3 to 9.5), and for the nondiabetic DSN is 5.76 (95% CI, 4.3 to 7.3). Age significantly predicted the onset of DSN both in diabetic individuals (for every increasing year of age RR = 1.07; 95% CI, 1.01 to 1.14) and in the entire study population (RR = 1.05; 95% CI, 1.02 to 1.09). Conclusions: We provide the first population-based distal symmetric neuropathies incidence data, as well as prevalence rates from an unselected sample of Italian elderly. Distal symmetric neuropathies are an age-associated condition, but the frequency of diabetic distal symmetric neuropathies declines with age, coincident with an increase in nondiabetic cases.

Any strategy to reduce stroke burden involves crucial inputs from individuals (risk reduction, rapid recognition and response to symptoms onset) which imply a certain level of stroke knowledge. Health-related applications (apps) have been identified as a novel platform for dissemination of health information to the public. Only few apps about stroke are currently available with scientifically valid information, none of them are available in Italian. We developed the first and only Italian stroke app, ICTUS3R. We also pilot tested ICTUS3R in terms of its usage during the first 12 months following release (October 30, 2014). ICTUS3R was developed in collaboration with communication experts, stroke leaders and web producers. ICTUS3R was pilot tested in terms of number and distribution of downloads. Data about 1 year usage were anonymously collected from ICTUS 3R release on October 30, 2014. ICTUS3R includes a stroke screening tool, information how to react in case of suspected stroke, and information about risk factors including personal stroke risk calculator. ICTUS 3R web site was visited 36,242 times. Mean session duration was over 2 min. The 48 % of downloads were by individuals aged 25–44 years, 12 % by individuals ≥55 years. ICTUS3R downloads were distributed across all the Italian provinces, in varying proportions. The 4.3 % of downloads were done outside Italy. ICTUS3R can be an important contribution to stroke management and prevention, it proved to be well received for dissemination of stroke information among Italians. Its use could contribute to reduce stroke burden in Italy.

Background Information on determinants and prognosis of ischemic stroke subtypes is scarce. We aimed at evaluating risk factors, pathogenesis, treatment and outcome of different ischemic stroke subtypes. Methods In a European Concerted Action involving seven countries, ischemic stroke subtypes defined according to the Oxfordshire Community Stroke Project (OCSP) were evaluated for demographics, baseline risk factors, resource use, 3-month survival, disability (Barthel Index) and handicap (Rankin Scale). Results During the 12-month study period, cerebral infarction was diagnosed in 2740 patients with first-in-a-lifetime stroke (mean age 70.5 ± 12.4 years, 53.4% males). OCSP classification was achieved in 2472 (90.2%). Of these, 26.7% were total anterior circulation infarctions (TACI), 29.9% partial anterior circulation infarctions (PACI), 16.7% posterior circulation infarctions (POCI) and 26.7% lacunar infarctions (LACI). In multivariate analysis, atrial fibrillation was predictive of TACI (odds ratio [OR], 1.61; 95% CI, 1.28–2.03), hypertension (OR, 1.38; 95% CI, 1.16–1.65) and myocardial infarction (OR, 1.42; 95% CI, 1.08–1.86) predictive of PACI, hypertension (OR, 1.25; 95% CI, 1.04–1.50) predictive of LACI. A negative association was observed between TACI and hypertension (OR, 0.51; 95% CI, 0.42–0.61). Discharge home was 50% less probable in TACI and PACI than in LACI patients. As compared to LACI, TACI significantly increased the risk of 3-month death (OR, 5.73; 95% CI, 3.91–8.41), disability (OR, 3.27; 95% CI, 2.30–4.66) and handicap (OR, 2.71; 95% CI, 1.91–3.85). Conclusions Ischemic stroke subtypes have different risk factors profile, with consequences on pathogenesis and prognosis. Information on determinants of the clinical syndromes may impact on prevention and acute-phase interventions.

Background and Purpose— The information on the existence of sex differences in management of stroke patients is scarce. We evaluated whether sex differences may influence clinical presentation, resource use, and outcome of stroke in a European multicenter study. Methods— In a European Concerted Action involving 7 countries, 4499 patients hospitalized for first-in-a-lifetime stroke were evaluated for demographics, risk factors, clinical presentation, resource use, and 3-month survival, disability (Barthel Index), and handicap (Rankin Scale). Results— Overall, 2239 patients were males and 2260 females. Compared with males, female patients were significantly older (mean age 74.5±12.5 versus 69.2±12.1 years), more frequently institutionalized before stroke, and with a worse prestroke Rankin score (all values P P =0.007) and atrial fibrillation ( P P P P =0.001), swallowing problems ( P =0.005), and urinary incontinence ( P P P Conclusions— Sex-specific differences existed in a large European study of hospital admissions for acute stroke. Both medical and sociodemographic factors may significantly influence stroke outcome. Knowledge of these determinants may positively impact quality of care.

This article represents the update of ‘European Stroke Initiative Recommendations for Stroke Management’, first published in this Journal in 2000. The recommendations are endorsed by the 3 European societies which are represented in the European Stroke Initiative: the European Stroke Council, the European Neurological Society and the European Federation of Neurological Societies.

Stroke knowledge improves public behavior in terms of prevention, symptom recognition, and timely response. Contemporary data on stroke awareness in the Italian general population are lacking. This study surveyed public knowledge of risk factors, warning signs, and proper reactions to stroke among Italian adults. A population-based telephone survey was carried out in a sample of 1,000 residents aged ≥18 years in May–June 2010. The questionnaire included close-ended questions focused on stroke symptoms, risk factors, and treatment options. We examined the prevalence and distribution of stroke knowledge in the community and generated multivariable logistic regression models. Among the 1,000 participants (481 men, mean age 48.8 ± 17.2), only the 55.8 % correctly identified the brain as the affected organ in stroke. The most common risk factor for stroke identified by respondents was hypertension (67.6 %), the most common warning sign was hemiparesis (68.7 %), the 43.5 % could list >1 warning sign. Multivariate analyses indicate that education and previous stroke experience are the only independent predictors of stroke knowledge. Only 26.2 % reported to know about the availability of t-PA treatment. An ambulance would be called by 59 % of respondents in the event of a stroke. Respondents with a high level of education are more likely to call an ambulance in case of stroke. This study provides the first comprehensive data describing stroke knowledge among Italian adults: the general level is suboptimal and is associated only with education and previous family experience of stroke. Public education could potentially improve treatment and prevention.

Aim This study assessed the prevalence of depressive symptomatology (DS) in older individuals with diabetes to determine whether diabetes and DS are independent predictors of mortality, and if their coexistence is associated with an increased mortality risk. Methods Analyses were based on data from the Italian Longitudinal Study on Aging (ILSA), a prospective community-based cohort study in which 5632 individuals aged 65–84years were enrolled. The role of diabetes and DS in all-cause mortality was evaluated using the Cox model, adjusted for possible confounders, for four groups: 1) those with neither diabetes nor DS (reference group); 2) those with DS but without diabetes; 3) those with diabetes but no DS; and 4) those with both diabetes and DS. Results Type 2 diabetes mellitus (T2DM) was present in 13.8% of the participants; they presented with higher baseline rates of DS compared with the non-diabetic controls. During the first follow-up period, participants with DS but not diabetes had a 42% higher risk of all-cause mortality compared with the reference control group (HR=1.42; 95% CI: 1.02–1.96), while participants with diabetes but not DS had an 83% higher risk of death than the reference group (HR=1.83; 95% CI: 1.19–2.80). The risk of death for those with both disorders was more than twice that for the reference group (HR=2.58; 95% CI: 1.55–4.29). Analyses of deaths from baseline to the second follow-up substantially confirmed these results. Conclusion The prevalence rate of DS is higher in elderly people with diabetes and their coexistence is associated with an increased mortality risk.

The Italian Longitudinal Study on Aging (ILSA) is a population-based, longitudinal study of the health status of Italians aged 65-84 years. The main objectives of ILSA are the study of the prevalence and incidence rates of common chronic conditions in the older population, and the identification of their risk and protective factors. ILSA is also designed to assess age-associated physical and mental functional changes. A random sample of 5632 individuals, stratified by age and gender using the equal allocation strategy, was identified on the demographic lists of the registry office of eight municipalities: Genova, Segrate (Milano), Selvazzano-Rubano (Padova), Impruneta (Firenze), Fermo (Ascoli Piceno), Napoli, Casamassima (Bari), and Catania. An extensive investigation, including interviews, physical exams, and laboratory tests, was conducted at baseline to identify the presence of cardiovascular disease (ischemic heart disease, hypertension, congestive heart failure, arrhythmia, intermittent claudication), diabetes, impaired glucose tolerance, thyroid dysfunction, dementia, parkinsonism, stroke, and peripheral neuropathy, as well as assess physical and mental functional status. The baseline examination was carried out between March 1992 and June 1993; a second comprehensive examination will begin in March 1995. An interim hospital discharge data survey and a mortality survey are currently ongoing to assess the hospitalization rate and the cause-specific mortality rate in this study cohort.

Background and aims A protective effect of moderate alcohol consumption on the cardiovascular system has consistently been reported, but limited evidence has been produced on the association of alcohol with metabolic factors in the elderly. The aim of this study was to investigate the association between different levels of current alcohol consumption and cardiovascular risk factors in a representative sample of elderly Italian men, mainly wine drinkers. Methods and results This is a cross-sectional multi-centre study on a population-based sample of Italian men aged 65–84 years, drawn from the Italian Longitudinal Study on Aging (ILSA) cohort. The analyses included 1896 men. Almost all the drinkers (98%) drank wine as a lifelong habit. Adjusted ORs for risk levels for cardiovascular factors (BMI, waist circumference, fibrinogen, α 2 protein, white blood cells, HDL cholesterol, Apo A-I, total cholesterol, Apo B-I, triglycerides, LDL, glycated hemoglobin, insulin, fasting plasma glucose, HOMA IR, systolic and diastolic blood pressure) were estimated, comparing drinkers with teetotalers using multivariate logistic regression models. We found alcohol consumption in older age associated with healthier hematological values of fibrinogen, HDL cholesterol, Apo A-I lipoprotein and insulin, but it was also associated with a worse hematological picture of total, LDL cholesterol levels, and systolic pressure. Conclusion Our results indicated in elderly moderate wine drinkers a noticeably safe metabolic, inflammatory and glycemic profile that might balance higher blood pressure, leading to a net benefit. These findings however need to be placed in relation to the known adverse social and health effects of heavy drinking.

Although there is plenty of evidence of the association between metabolic syndrome (MS) and cardiovascular disease, the relationship between alcohol consumption and MS is still questioned. The few publications with respect to the elderly seem to indicate that alcohol consumption is unassociated with MS. The aim of this study was to assess the association between alcohol consumption and the prevalence and incidence of MS, as well as its components in a large sample of Italian elderly people.This is a multicenter study on a population-based sample of Italian people aged 65-84 years. The Italian Longitudinal Study on Aging (ILSA) included a prevalence phase in 1992 and an incidence phase from 1995 to 1996. The median length of follow-up was 3.5 years. In the present study, the analysis included 1321 men grouped into five alcohol consumption classes: abstainers, and those consumingor=12, 13-24, 25-47 oror=48 g of alcohol in a day. Among the 1122 women considered, the last two of the above five categories were pooled together (24 g/day). MS was defined according to ATP III criteria. All statistical analyses were stratified by gender.Adjusted odds ratios showed that categorized alcohol consumption was not significantly associated with the prevalence and incidence of MS when compared with abstainers in either gender. For the MS incidence survey, three of five components (systolic pressure, glycemia and waist circumference) proved to be significantly and harmfully affected by alcohol consumption in males, whereas no such significant association emerged in females.These results suggest that alcohol can modify an individual's metabolic condition and that, even among the elderly, men might be more sensitive to the effects of alcohol than women.

Central nervous system (CNS) involvement was detected during infection caused by the sand fly-transmitted Phlebovirus Toscana. One hundred fifty-five cases of Toscana virus-associated meningitis or meningoencephalitis were identified in a survey that lasted ten years, conducted in two regions of central Italy. Diagnosis was performed by different serologic tests. A combination of hemagglutination-inhibition and plaque-reduction neutralization or indirect immunofluorescence for IgM, and enzyme-linked immunosorbent assays for IgM were considered the most suitable tests for the diagnosis of Toscana virus infection. A few strains of Toscana virus were isolated from the cerebrospinal fluid of seropositive patients. Toscana virus-associated CNS disease occurred during the summer, reaching a peak value in August, when the maximum activity of the sand fly vector occurs and virus isolates are obtained in their natural foci. The results suggest that Toscana virus should be considered as a possible cause of CNS disease in Mediterranean countries where sand flies of the genus Phlebotomus are known to be present.

The relationship between mortality and marital status has long been recognized, but only a small number of investigations consider also the association with cohabitation status. Moreover, age and gender differences have not been sufficiently clarified. In addition, little is known on this matter about the Italian elderly population. The aim of this study is to examine differentials in survival with respect to marital status and cohabitation status in order to evaluate their possible predictive value on mortality of an Italian elderly cohort. This paper employs data from the Italian Longitudinal Study on Aging (ILSA), an extensive epidemiologic project on subjects aged 65-84 years. Of the 5376 individuals followed-up from 1992 to 2002, 1977 died, and 1492 were lost during follow-up period. The baseline interview was administered to 84% of the 5376 individuals and 65% of them underwent biological and instrumental examination. Relative risks of mortality for marital (married vs. non-married) and cohabitation (not living alone vs. living alone) categories are estimated through hazard ratios (HR), obtained by means of the Cox proportional hazards regression model, adjusting for age and several other potentially confounding variables. Non-married men (HR=1.25; 95% CI: 1.03-1.52) and those living alone (HR=1.42; 95% CI: 1.05-1.92) show a statistically significant increased mortality risk compared to their married or cohabiting counterparts. After age-adjustment, women's survival is influenced neither by marital status nor by cohabitation status. None of the other covariates significantly alters the observed differences in mortality, in either gender. Neither marital nor cohabitation status are independent predictors of mortality among Italian women 65+, while among men living alone is a predictor of mortality even stronger than not being married. These results suggest that Italian men benefit more than women from the protective effect of living with someone.

to provide information on epidemiology of dementia in Tuscany needed to plan for dedicated health and social services.analysis of pooled baseline data from 4 population-based longitudinal studies.4 municipalities in Tuscany.4,056 elderly subjects enrolled in 4 longitudinal studies.age- and sex-specific dementia prevalence rates and estimated number of demented people, by degree of cognitive impairment and BADL disability in the elderly population of Tuscany.out of the evaluated subjects, 293 are demented. Prevalence of dementia increases from about 1 % in the 65-69 age group to about 28 % in the 90+ age group both among women and men. About 43% of the demented study subjects suffer from severe mental deterioration (MMSE14) and56% are disabled in at least one Basic Activity of Daily Living (BADL). We estimate that about 19 thousand demented elderly men and 40 thousand demented elderly women are currently living in Tuscany of whom 26 thousand severely mentally impaired and 34 thousand disabled in at least one BADL. The resulting overall dementia prevalence standardised on the Italian 65+ population is 5,3% for men and 7,7% for women.these estimates could be used as a basis for the evaluation and the planning of social and health care services dedicated to demented people.

Background and objective Previous myocardial infarction (MI) has been linked with poorer stroke outcome. Whether this depends on a greater stroke severity is still uncertain. The aim of the study was to assess the effect of previous MI on characteristics and outcome of stroke in a large hospital cohort of patients. Methods In a European Union Concerted Action, patients hospitalized for first-in-a-lifetime stroke were assessed for demographics, risk factors, clinical presentation, and 3-month survival and handicap. Results Out of 4190 study patients, 460 (11%) reported a history of MI. Compared with patients without previous MI, those with MI were significantly older, more often males, smokers, alcohol consumers, and with a more severe pre-stroke level of handicap. They had more frequently atrial fibrillation and a history of transient ischemic attack. The acute neurological state and the 28-day mortality did not differ between the two groups. At 3 months, death or severe handicap were more frequent in the MI group (28.3% vs. 21.7%, P =0.001; 74.8% vs. 65.8%, P =0.008). Controlling by logistic regression analysis for age, sex, vascular risk factors, comorbidities, prior to stroke therapy, pre-stroke level of handicap, and clinical acute phase variables, prior MI remained an independent predictor of 3-month death (OR 1.30; 95% CI, 1.02–1.66) and 3-month handicap (OR 1.46; 95% CI, 1.01–2.11). Conclusions Previous MI has no impact on clinical severity of acute stroke, but significantly affects 3-month outcome in terms of handicap and mortality.

To examine risk and predictors of motor-performance (MP) decline targeting subjects performing normally at an initial observation.Cohort study.A subsample of the Italian Longitudinal Study on Aging (aged 65-84).One thousand fifty-two subjects (mean age+/-standard deviation = 71+/-5, 69% men) with normal MP at baseline.Six tests (standing up from a chair, stepping up, tandem walk, standing on one leg, walking speed, and steps turning 180 degrees ) were used to assess MP at baseline and after 3 years. Baseline characteristics were potential predictors of MP decline.Of the 1,052 subjects performing normally at baseline, 166 (15.8%) had declined in MP at follow-up. Older age, female sex, lower education, symptoms of distal symmetrical neuropathy, cognitive impairment without dementia, parkinsonism, heart failure, anemia, depressive symptoms, worse Mini-Mental State Examination score, and lost activities of daily living and instrumental activities of daily living (IADLs) were significantly associated with MP decline in univariate comparisons. Older age (odds ratio (OR) = 3.84, 95% confidence interval (CI) = 2.14-6.88 comparing age classesor =80 with 65-69), female sex (OR=1.50, 95% CI = 1.03-2.20), distal symmetric neuropathy (OR = 2.00, 95% CI = 1.03-3.87), depressive symptoms (OR = 1.85, 95% CI = 1.17-2.24), and baseline IADLs (OR = 1.22, 95% CI = 1.08-1.37 for each lost activity) independently predicted MP decline after regression analysis.In a population-based cohort of elderly people with normal MP, one-sixth declined in 3 years. Age, sex, distal symmetrical neuropathy, depressive symptoms, and baseline IADLs independently predicted this decline. Distal symmetrical neuropathy is underestimated in the clinical and epidemiological evaluation of motor decline in older people.

The occurrence of behavioral and psychological symptoms of dementia (BPSD) is currently recognized as an important aspect of Alzheimer’s disease (AD). We evaluated the frequency and severity of BPSD with the Neuropsychiatric Inventory across the various degrees and phases of the disease in 50 consecutive AD outpatients. Apathy, aberrant motor activity, dysphoria and anxiety were the symptoms most frequently reported by the caregivers, ranging in the whole study sample from 46 to 74%. A clear trend towards increasing frequency with the severity of disease was found for delusions, hallucinations and aberrant motor activity. A major effect of the duration of the disease was found in the probability of developing hallucinations and aberrant motor activity. Apart from hallucinations, all BPSD were present starting from a mild degree of dementia. A better understanding of the global spectrum of BPSD in AD is warranted in order to improve the allocation of health resources toward the treatment of dementia.

OBJECTIVES: To analyze the relationship between serum total cholesterol (TC) and all-cause mortality, taking into account various potential confounders. DESIGN: Population-based prospective cohort study. SETTING: Older Italians residing in the general community. PARTICIPANTS: Four thousand five hundred twenty-one men and women aged 65–84. MEASUREMENTS: Vital status data were available for 1992–95. The hazard ratios of dying for subjects in the second, third, and fourth quartiles compared with the first quartile of TC were computed using Cox proportional hazards, adjusting for lifestyle factors, anthropomorphic and biochemical measures, preexisting medical conditions, and frailty indicators. RESULTS: Blood samples were obtained from 3,295 (73%) of the participants, of whom 399 died during almost 3 years of follow-up. Low TC was associated with a higher risk of death. Those with TC in the second, third, and fourth quartiles (TC>189 mg/dL or 4.90 mmol/L) had lower hazard ratios (HRs) of death than subjects in the first quartile (0.57, 95% confidence interval (CI) = 0.38–0.87; 0.56, 95% CI = 0.36–0.88; and 0.53, 95% CI = 0.33–0.84, respectively). Few subjects taking lipid-lowering drugs (LLDs) were in the lowest quartile of cholesterol, suggesting that these individuals have low TC values for reasons other than LLD use. CONCLUSION: Subjects with low TC levels (

Data on stroke morbidity are lacking in southern Italy, an area with about 20 million inhabitants and a mean income lower than the rest of the country. Therefore a population-based stroke register was established to determine incidence and case fatality in the Province of Vibo Valentia, Calabria.The survey was conducted among the 179186 residents. Standard definitions and multiple case-finding procedures were employed. All identified cases of first-ever stroke were followed at 28 days, 3 and 12 months. The registration started on January 1, 1996, and ended on December 31, 1996.A total of 321 first-ever-in-a-lifetime strokes were identified. The crude annual incidence rate was 1.79 (95% CI 1.60-1.99) per 1000 inhabitants. Rates age-standardized to the 1996 Italian population and to the standard European population were, respectively, 1.99 (95% CI 1.79-2.20) and 1.36 (95% CI 1.19-1.53) per 1000 inhabitants. A subtype diagnosis was reached in 96% of patients. The crude annual incidence rates per 1000 inhabitants were 1.31 for cerebral infarction, 0.35 for intracerebral hemorrhage, 0.06 for subarachnoid hemorrhage, and 0.07 for unspecified stroke. Overall case fatality was 23.7% at 28 days, 27.4% at 3 months and 40.2% at 12 months.This is the first prospective population-based stroke register established in southern Italy. Incidence and case fatality were comparable to those previously reported in northern and central Italy and other industrialized countries. Our estimates are useful for developing management services and allocating resources.

Epidemiological data are essential to estimate the burden of stroke. We evaluated stroke incidence in older Italians and the effect of first-ever stroke on survival and activities of daily living (ADL).The analysis was performed in the Italian Longitudinal Study on Aging (ILSA) sample, consisting of 5,632 individuals aged 65-84. The ILSA aims at major cardiovascular and neurological age-associated diseases. The baseline survey was performed in 1992 to detect prevalent diseases. The longitudinal examination started on September 1995 aiming at incidence, function and survival.Complete follow-up data were achieved for 77% of the baseline stroke-free cohort (4,164 persons; 50.9% males; mean age 74.5 +/- 5.7 years). Incidence for first-ever stroke was 9.51 (95% CI: 7.75-11.27) per 1,000 person years and 12.99 (95% CI: 10.99-14.98) including recurrent stroke (total incidence). Crude mortality was 49.2% among first stroke patients and 15% among persons without stroke. The first-ever stroke mortality risk ratio, adjusted for demographics and comorbidity, was 2.40 (95% CI: 1.62-3.54). In survivors, impairment of at least one ADL was present in 67.6% of first-ever stroke patients vs. 31.6% of individuals without stroke. The comorbidity-adjusted OR was 2.63 (95% CI: 1.20-5.78) in the total cohort, and 4.00 (95% CI: 1.39-11.46) in individuals without disability at baseline.The ILSA provides the first data on stroke incidence in Italy on a national basis. Overall, 153,000 new cases can be expected annually in the Italian elderly population. First-ever stroke still has a strong effect on survival and function of older persons.

The Italian Longitudinal Study on Aging (ILSA) evaluates the rates of diabetes, cardiovascular and neurological disorders in a random sample of 5632 Italians aged 65-84 years.The ILSA has two components: a first screening phase administered to all participants, that includes a personal interview, physician examination, laboratory and diagnostic tests, and a second phase, consisting of the clinical confirmation of suspected cases by a specialist.Prevalence rates were significantly higher among men for myocardial infarction (10.7% versus 4.8%), cardiac arrhythmia (25.1% versus 20.3%) and peripheral artery disease (8.1% versus 5.2%), and among women for hypertension (67.3% versus 59.4%), heart failure (7.3% versus 5.4%) and dementia (7.2% versus 5.3%). No gender difference was found for stroke, angina, diabetes, Parkinsonism and distal symmetric neuropathy. Unreported diagnoses accounted for 85% of cases of distal symmetric neuropathy, for more than half the cases of cardiac failure, for 40% of cases of angina, and for more than one-third of cases arrhythmia, myocardial infarction, peripheral artery disease, hypertension, Parkinsonism. Data from the phase 1 interview showed substantial overreporting for myocardial infarction, peripheral artery disease, diabetes, and stroke.The authors conclude that self-reported information would lead to inaccurate estimates of prevalence rates suggesting the need for including the clinical ascertainment in any population-based epidemiological study.

In two patients with lack of spontaneous activity and emotionality, without dementia or depression and in absence of other neurologic signs, the "athymormia syndrome" has been diagnosed. CT scan and MRI showed bilateral symmetrical lesions in basal ganglia. We discuss the possible pathophysiological basis of the syndrome and the recent data about the functional connections among basal ganglia, frontal cortex and limbic system.

Summary Background Previous studies of variation in the magnitude of socioeconomic inequalities in health between countries have methodological drawbacks. We tried to overcome these difficulties in a large study that compared inequalities in morbidity and mortality between different countries in western Europe. Methods Data on four indicators of self-reported morbidity by level of education, occupational class, and/or level of income were obtained for 11 countries, and years ranging from 1985 to 1992. Data on total mortality by level of education and/or occupational class were obtained for nine countries for about 1980 to about 1990. We calculated odds ratios or rate ratios to compare a broad lower with a broad upper socioeconomic group. We also calculated an absolute measure for inequalities in mortality, a risk difference, which takes into account differences between countries in average rates of illhealth.

BACKGROUND Studies on the association between depressive symptomatology (DS) and cardiovascular events and mortality in elderly persons have yielded contradictory findings. To address this issue, the authors assessed DS and an extensive array of sociodemographic, behavioral, and biological variables in the largest population-based sample of older Italians ever studied and analyzed their association with coronary heart disease (CHD) morbidity and total number of deaths. METHODS This prospective, community-based cohort study included a sample of 5632 Italians, 65 years and older, who were recruited from the demographic registries of eight municipalities in Italy. Depressive symptomatology was assessed using the Geriatric Depression Scale, and a score > or =10 was used to indicate the presence of DS. All traditional cardiovascular disease risk factors were assessed at baseline, through questionnaires, blood tests, and physical examinations. The outcomes were CHD fatal and nonfatal events and total number of deaths. The association of the predictive variables with the outcomes was assessed using different Cox models. RESULTS Baseline DS was associated with a higher incidence of fatal and nonfatal CHD events (hazard ratio [HR], 1.66; 95% confidence interval [CI], 1.06-2.60) and with cardiovascular mortality in men (HR, 2.49; 95% CI, 1.60-3.87) and with total mortality in men (HR, 2.02; 95% CI, 1.58-2.58) and women (HR, 1.43; 95% CI, 1.04-1.95) at the 4-year follow-up assessment. This association was observed after adjusting for a vast array of potential confounding variables, including major chronic conditions. CONCLUSIONS Depressive symptomatology confers an increased risk for CHD in men and for total mortality in men and women but is not explained by health behaviors, social isolation, or biological or clinical determinants.

OBJECTIVES: To investigate prevalence of “cognitive impairment, no dementia” (CIND) in the Italian older population, evaluating the association with cardiovascular disease and the impact on activities of daily living (ADL). CIND may provide pathogenic clues to dementia and independently affect ADL. DESIGN: Cross-sectional examination in the context of the Italian Longitudinal Study on Aging. SETTING: Random population sample from eight Italian municipalities. PARTICIPANTS: A total of 3425 individuals aged 65–84 years, residing in the community or institutionalized. MEASUREMENTS: Study participants were screened for cognitive impairment by using the Mini-Mental State Examination. Trained neurologists examined those scoring

Remarkable differences among European countries have been found in stroke rehabilitation models, owing to the fact that stroke rehabilitation services are embedded in health care systems. Comprehensive data on service utilization by stroke survivors in Italy are lacking, but would be instrumental in improving efficiency and effectiveness of post-acute stroke care, and consequently, in containing costs and improving outcomes.The purpose of the present study was to survey the Italian regional legislations in order to examine the provision of rehabilitation services for stroke survivors in Italy.This is a cross-sectional, observational study.Post-stroke intra- and extra-hospital rehabilitation.All decrees and resolutions as to post-acute stroke rehabilitation were collected from each Italian region.All decrees and resolutions were examined by the means of a check list including quantitative and qualitative characteristics, selected in accordance with national official recommendations. Each completed check list was then sent to each regional reference person, who filled in the section on the implementation of the indications and compliance.The study was carried out from November 2009 to September 2010. The documents were collected from 19 out of the 20 Italian regions. The results of the study indicate that there are many, remarkable regional variations in health policies concerning post-stroke care. Instruments for evaluation and criteria for allocating stroke patients to proper rehabilitation setting vary across regions, but data on the potential impact of these variations on clinical outcomes are still lacking.The study highlights the issue that, in Italy, delivery of post-stroke rehabilitation services is not uniform nation-wide and varies substantially across regions. The lack of a comprehensive post-acute stroke strategy is a major obstacle to service availability.The study results advocate the need for a consistent and comprehensive strategic planning of post-stroke rehabilitation in Italy.

BACKGROUND The inverse relationship of insulin level to high-density lipoprotein (HDL)-cholesterol and its positive association with hypertriglyceridemia has been demonstrated in several studies; however, the relationship of insulin to low-density lipoprotein (LDL)-cholesterol in elderly persons is not clear. This study investigates the relationships of fasting plasma insulin and selected metabolic and biological risk factors in an aged population. METHODS The present study is based on a cross-sectional analysis of the data collected at baseline of the Italian Longitudinal Study on Aging in 1992 on a random sample of 5632 Italians aged 65-84 years. Analyses were performed to compare the distribution of risk factors, such as blood level of lipids, creatinine, albumin, fibrinogen, apolipoprotein A-1 and B, blood pressure, and body mass index (BMI), by quartiles of insulin, in both diabetic and nondiabetic participants. RESULTS Significantly higher levels of triglycerides and BMI and lower levels of HDL-cholesterol were found in the upper quartile of insulin among nondiabetic individuals. In men, we also found significantly higher levels of systolic and diastolic blood pressure. The same trend for these variables, although not significant for HDL-cholesterol and blood pressure, was seen in diabetic men. In diabetic women, total and LDL-cholesterol were significantly lower in the highest insulin quartile (p

Background Dementia, including Alzheimer’s disease (AD), is one of the most burdensome medical conditions. In order to better understand the epidemiology of dementia in Italy, we conducted a systematic search of studies published between 1980 and April 2014 investigating the prevalence of dementia and AD in Italy and then evaluated the quality of the selected studies. Methods A systematic search was performed using PubMed/Medline and Embase to identify Italian population-based studies on the prevalence of dementia among people aged ≥60 years. The quality of the studies was scored according to Alzheimer’s Disease International (ADI) criteria. Results Sixteen articles on the prevalence of dementia and AD in Italy were eligible and 75 % of them were published before the year 2000. Only one study was a national survey, whereas most of the studies were locally based (Northern Italy and Tuscany). Overall, the 16 studies were attributed a mean ADI quality score of 7.6 (median 7.75). Conclusions Available studies on the prevalence of dementia and AD in Italy are generally old, of weak quality, and do not include all regions of Italy. The important limitations of the few eligible studies included in our analysis, mostly related to their heterogeneous design, make our systematic review difficult to interpret from an epidemiologic point of view. Full implementation of a Dementia National Plan is highly needed to better understand the epidemiology of the disease and monitor dementia patients.

The effect of dementia on time to death and institutionalization in elderly populations is of importance to resource planning, as well as to patients and their carers. The authors report a collaborative reanalysis of nine population-based studies conducted in Europe to compare dementia cases and noncases in risk of and time to death and to institutionalization. Prevalent and incident cases were more likely than noncases to reside in an institution at baseline and were more likely to enter institutional care. Prevalent cases also had over twice the risk of death compared to noncases and survival for men with dementia was consistently lower than that for women with dementia of the same age group.

Objective: To study the association of estrogen-replacement therapy and other estrogen-related variables with Alzheimer9s disease in postmenopausal women. Background: Postmenopausal estrogen use has been reported to lower the risk of Alzheimer9s disease. Design: A population-based, multicenter survey was carried out in eight Italian municipalities. The sample of 2,816 women, aged 65 to 84 years, was randomly selected from the population register of each municipality and stratified in 5-year age groups. All women were screened using the Mini-Mental State Examination and interviewed concerning risk factors. Those who screened positive underwent a clinical assessment. Dementia syndrome was diagnosed according to DSM-III-R criteria, and Alzheimer9s disease was diagnosed according to NINCDS-ADRDA criteria for possible and probable Alzheimer9s disease. Results: The estimated prevalence of postmenopausal estrogen use adjusted to the 1991 Italian female population was 12.3%. The frequency of estrogen use was higher among nonpatients compared with Alzheimer9s disease patients (odds ratio, 0.24; 95% confidence interval, 0.07 to 0.77). The inverse association between estrogen therapy and Alzheimer9s disease remained significant after adjustment for age, education, age at menarche, age at menopause, smoking and alcohol habits, body weight at the age of 50 years, and number of children(odds ratio, 0.28; 95% confidence interval, 0.08 to 0.98). Conclusions: Our data from a population-based study support the hypothesis that estrogen-replacement therapy is associated with a reduced prevalence of Alzheimer9s disease in postmenopausal women. Prospective clinical trials are required to enable women and their physicians to weigh risks and benefits of estrogen-replacement therapy for the prevention of dementia.