Ravaglia G, Forti P, Lucicesare A, Pisacane N, Rietti E, Bianchin M, Dalmonte E. Physical activity and dementia risk in the elderly: findings from a prospective Italian study. Neurology. 2008 May 6;70(19 Pt 2):1786-94. Epub 2007 Dec 19.

OBJECTIVE: To examine the effect of physical activity on risk of developing Alzheimer disease (AD) and vascular dementia (VaD) in the elderly. METHODS: Data are from a prospective population-based cohort of 749 Italian subjects aged 65 and older who, in 1999/2000, were cognitively normal at an extensive assessment for clinically overt and preclinical dementia and, in 2003/2004, underwent follow-up for incident dementia. Baseline physical activity was measured as energy expenditure on activities of different intensity (walking, stair climbing, moderate activities, vigorous activities, and total physical activity). RESULTS: Over 3.9 +/- 0.7 years of follow-up there were 86 incident dementia cases (54 AD, 27 VaD). After adjustment for sociodemographic and genetic confounders, VaD risk was significantly lower for the upper tertiles of walking (hazard ratio [HR] 0.27, 95% CI 0.12 to 0.63), moderate (HR 0.29, 95% CI 0.12 to 0.66), and total physical activity (HR 0.24, 95% 0.11 to 0.56) compared to the corresponding lowest tertile. The association persisted after accounting for vascular risk factors and overall health status. After adjustment for sociodemographic and genetic confounders, AD risk was not associated with measures of physical activity and results did not change after further adjustment for vascular risk factors and overall health and functional status. CONCLUSIONS: In this cohort, physical activity is associated with a lower risk of vascular dementia but not of Alzheimer disease. Further research is needed about the biologic mechanisms operating between physical activity and cognition.

Francesconi P, Gini R, Roti L, Bartolacci S, Corsi A, Buiatti E. The Tuscany experimental registry for Alzheimer's disease and other dementias: how many demented people does it capture? Aging Clin Exp Res. 2007 Oct;19(5):390-3.

BACKGROUND AND AIMS: A Regional Registry for Alzheimer's Disease and Other Dementias is being tested in Tuscany (Italy) to provide a basis for epidemiological studies. Current results are presented and critically evaluated. METHODS: The Registry extracts data on cases of dementia from Hospital Discharge Records, Outpatient Service Records, Regional Mortality Registry and Disease-Specific Co-payment Exemption Records, based on ICD-9 codes of dementias, and from Prescription Records based on registered anti-dementia drug codes. A list of cases of dementia prevalent at the end of 2005 was produced by cross-checking captured cases with the Regional Mortality Registry. RESULTS: The Registry captured 47,889 cases, of which 27,796 were still alive at the end of 2005. Captured cases represent slightly less than half of all the cases of dementia estimated to be present in Tuscany among older residents (65+) according to recent prevalence studies. Conversely, of 87 subjects 65 years of age or older selected from the Registry and directly evaluated, 80 (92%) were truly cognitively impaired subjects. CONCLUSIONS: The Registry has low sensitivity, probably because not all demented individuals are diagnosed as such in current practice and/or use health services. Conversely, the Registry has high specificity, and the produced lists of prevalent dementia cases are the key to estimating health and quality-of-care indicators for the demented population, and may constitute a basis for epidemiological studies.

Tognoni G, Ceravolo R, Nucciarone B, Bianchi F, Dell'Agnello G, Ghicopulos I, Siciliano G, Murri L. From mild cognitive impairment to dementia: a prevalence study in a district of Tuscany, Italy. Acta Neurol Scand. 2005 Aug;112(2):65-71.

OBJECTIVE: A door-to-door two-phase study was designed in order to estimate the prevalence of cognitive deficit amongst the residents of a district in Tuscany (central Italy). Identification of cases with mild cognitive impairment (MCI) was given high priority, because this condition has been suggested as a term for the boundary area between normal aging and dementia. METHODS: Of the 1600 subjects who completed the screening phase, 354 scored under the cut-off point of the Mini Mental State Examination and Clinical Dementia Rating and were investigated by means of a standardized diagnostic protocol. RESULTS: The prevalence of MCI and age-related cognitive decline was 4.9 and 9.3%, respectively; low levels of education significantly increased the risk of these conditions. The prevalence of dementia over age 65 was 6.2%, with a significant risk association with age. In our population, Alzheimer's disease was the most frequent type of dementia (prevalence rate 4.2%) and increased risk depending on age, sex and education has been found. CONCLUSIONS: Our findings are somewhat similar to previous studies. Further epidemiological and longitudinal studies are warranted to identify which diagnostic category is more predictive for dementia.

Greco A, Cascavilla L, Paris F, Errico M, Orsitto G, D'Alessandro V, Placentino G, Franceschi M, Seripa D, Vendemiale GL, Pilotto A. Undercoding of Alzheimer's disease and related dementias in hospitalized elderly patients in Italy. Am J Alzheimers Dis Other Demen. 2005 May-Jun;20(3):167-70.

The prevalence of Alzheimer's disease (AD) and AD-related dementias (ADRD) in acute ward-hospitalized elderly patients is not well known, owing principally to misclassification and undercoding of AD and ADRD on hospital discharge abstract forms (DAFs). The aims of this study were to evaluate the prevalence of AD and ADRD, as evaluated by the DAF in elderly patients hospitalized in acute wards, and to compare clinical severity, length of stay, comorbidity, and number of diagnostic procedures in patients with AD versus ADRD to explain the different reimbursement costs of DRG12 (AD) versus DRG429 (ADRD). From the inpatient DAF database of the Casa Sollievo della Sofferenza Hospital, the DAFs of patients aged 65 years or over discharged from January 1, 2001, to March 31, 2003, with principal or secondary diagnoses of AD (ICD9-CM code 331) or ADRD (ICD9-CM codes from 290.0 to 290.43) were extracted and grouped by APR-grouper version 12. Age, gender, length of stay, principal and secondary diagnoses and procedures, and APR-DRG severity index (SI) and mortality risk (MR) were evaluated in these patients. Senile dementia was reported in 294 patients (0.58 percent, N = 50,253). In 123 patients (41.8 percent) dementia was the principal diagnosis, whereas in 171 patients (58.2 percent) dementia was reported on the DAF as a secondary diagnosis. Of the 123 patients with a principal diagnosis of dementia, 35 patients were included in the DRG-12 (AD) and 88 patients were included in the DRG-429 (ADRD). No differences were found in mean age, length of stay, comorbidity, or number of diagnostic procedures, as well as in the APR-DRG SI and APR-DRG MR between AD and ADRD patients. Conversely, reimbursement amounts were established as Euro4,033 for DRG-12 (AD) and Euro2,952 for DRG-429 (ADRD). AD and ADRD are undercoded in elderly hospitalized patients. The limits of the ICD9-CM classification system and the influence of reimbursement amounts may influence the coding reports by physicians.

Ravaglia G, Forti P, Maioli F, Martelli M, Servadei L, Brunetti N, Dalmonte E, Bianchin M, Mariani E. Incidence and etiology of dementia in a large elderly Italian population. Neurology. 2005 May 10;64(9):1525-30.

OBJECTIVE: To estimate age- and sex-specific incidence of dementia, Alzheimer disease (AD), and vascular dementia (VaD) in the Conselice Study of Brain Aging, an Italian prospective population-based study, and to assess whether poor education is a risk factor for dementia. METHODS: In 1999 to 2000, the baseline study identified a dementia-free cohort of 937 subjects aged 65 years and older who were reexamined in 2003 to 2004 using a two-phase procedure. RESULTS: Information was obtained for 91% of the subjects at risk; 115 incident cases of dementia were identified. Incidence rates per 1,000 person-years were 37.8 (95% CI = 30.0 to 47.7) for dementia, 23.8 (95% CI = 17.3 to 31.7) for AD, and 11.0 (95% CI = 7.2 to 16.9) for VaD. This translates into more than 400,000 new cases of dementia expected per year in Italy. Increasing age was an independent risk factor for both AD and VaD. Poor education was an independent risk factor for AD but not VaD. Sex did not affect dementia risk. CONCLUSIONS: In this Italian population-based cohort, incidence of dementia increased with age, and Alzheimer disease (AD) was the most frequent type of dementia. Poor education was associated with a higher risk of AD. Our incidence rates are higher than previously reported in Italy, and provide new estimates for projection of future burden of disease in Italy.

De Ronchi D, Berardi D, Menchetti M, Ferrari G, Serretti A, Dalmonte E, Fratiglioni L. Occurrence of cognitive impairment and dementia after the age of 60: a population-based study from Northern Italy. Dement Geriatr Cogn Disord. 2005;19(2-3):97-105.

OBJECTIVE: To evaluate the age, gender and education distribution of both cognitive impairment and dementia in the whole old age range of the elderly (from 61 years of age and over). SUBJECTS AND METHODS: The study population consisted of all subjects born in 1930 or before, living in the municipality of Faenza and Granarolo, Italy (n = 7,930). A two-phase study design was implemented, by using the Mini-Mental State Examination and Global Deterioration Scale as screening instruments. The DSM-III-R diagnostic criteria were used for the clinical diagnosis of dementia. A subject was classified as affected by cognitive impairment, no dementia (CIND) if he/she scored 2 or more standard deviations lower than the corrected mean MMSE score. RESULTS: The prevalences of dementia and CIND were 6.5 per 100 (95% CI 5.9-7.0) and 5.1 per 100 (95% CI 4.6-5.6), respectively. The prevalence of CIND was higher than that of dementia in the youngest old groups (61-74 years), both in men and women, whereas the opposite pattern was present among the older old (75+). In the older age groups, dementia prevalence increased exponentially with age, while CIND prevalence was more stable. There was not a substantial gender difference in CIND prevalence in all ages. Only in the subpopulation of higher educated subjects, women had a higher prevalence of both dementia and CIND than men. Lower educated subjects had a higher prevalence of both dementia and CIND. When compared to higher educated persons, subjects without any schooling had odds ratios of 10.9 (CI 7.0-16.7) and 16.7 (CI 11.2-25.0) for dementia and CIND, respectively. CONCLUSIONS: Cognitive impairment is very common in the younger old ages (under 70 years of age), whereas dementia becomes predominant after 75 years of age. Both conditions are strongly related to the educational level.

Ravaglia G, Forti P, Maioli F, Sacchetti L, Mariani E, Nativio V, Talerico T, Vettori C, Macini PL. Education, occupation, and prevalence of dementia: findings from the Conselice study. Dement Geriatr Cogn Disord. 2002;14(2):90-100.

Information about the epidemiology of dementia in Italy is still limited, although this cognitive disorder represents a serious public health concern. We estimated the prevalence of dementia and dementia subtypes in the elderly population of a Northern Italian municipality, Conselice, in the Emilia Romagna region (n = 1,016 subjects aged 65-97 years). The associations of dementia with two modifiable risk factors, education and occupation, were also evaluated. Overall dementia prevalence was 5.9% (95% confidence interval 4.3-7.8), exponentially increased with age, and was higher among women. Of the dementia cases, 50% were Alzheimer's disease (AD), but an unusually high prevalence (45%) was found for vascular dementia (VD). After adjustment for age and gender, education but not occupation was associated with both AD and VD. This association could not be explained by occupation, life habits, and previous history of hypertension or cardiovascular disease.

Di Carlo A, Baldereschi M, Amaducci L, Lepore V, Bracco L, Maggi S, Bonaiuto S, Perissinotto E, Scarlato G, Farchi G, Inzitari D; ILSA Working Group. Incidence of dementia, Alzheimer's disease, and vascular dementia in Italy. The ILSA Study. J Am Geriatr Soc. 2002 Jan;50(1):41-8.

OBJECTIVES: To estimate the incidence of dementia, Alzheimer's disease (AD), and vascular dementia (VaD) in older Italians and evaluate the relationship of age, gender, and education to developing dementia. DESIGN: Cohort incidence study in the context of the Italian Longitudinal Study on Aging. SETTING: Population sample from eight Italian municipalities. PARTICIPANTS: A dementia-free cohort of 3,208 individuals (aged 65-84), individuated after a baseline evaluation performed in 1992 / 93, aimed at detecting prevalent cases. MEASUREMENTS: The dementia-free cohort was reexamined in 1995 to identify incident cases. The Mini-Mental State Examination (cutoff 23 / 24) was employed to screen for dementia. Trained neurologists evaluated the individuals who screened positive. Final diagnoses had to meet Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised criteria for dementia, National Institute of Neurological and Communicative Disorders and Stroke-Alzheimer's Disease and Related Disorders Association criteria for AD, and International Classification of Diseases, Tenth Revision criteria for VaD. RESULTS: Before the follow-up examination, 382 individuals had died (232 had reliable information). Of the 2,826 survivors, 2,266 completed the study. Overall, 127 new dementia cases were identified. Average incidence rates per 1,000 person-years were 12.47 (95% confidence interval (CI)=10.23-14.72) for dementia, 6.55 (95% CI=4.92-8.17) for AD, and 3.30 (95% CI=2.14-4.45) for VaD. Both AD and VaD showed age-dependent patterns. Education was protective against dementia and AD. Women carried a significantly higher risk of developing AD (hazard ratio=1.67, 95% CI=1.02-2.75), and men of developing VaD (hazard ratio=2.23, 95% CI=1.06-4.71). CONCLUSIONS: Incidence of dementia in Italy paralleled that in most industrialized countries. About 150,000 new cases per year are expected. A significant gender effect was evidenced for major dementia subtypes. The burden of VaD, especially in men, offers opportunities for prevention.

Ferini-Strambi L, Marcone A, Garancini P, Danelon F, Zamboni M, Massussi P, Tedesi B, Smirne S. Dementing disorders in north Italy: prevalence study in Vescovato, Cremona Province. Eur J Epidemiol. 1997 Feb;13(2):201-4.

We investigated the prevalence of dementia in 673 subjects over 59 years of age in Vescovato, a small town of North Italy, using a two-phase survey. During phase I all subjects were administered the Hodkinson abbreviated mental test and the subjects with a score < or = 7 underwent further examination to ascertain the diagnosis of dementia. The prevalence ratio of dementia of all types was 9.8% (7.6-12.0, 95% CI) above age 59. In our population Alzheimer's disease (AD) was the most frequent type of dementia (prevalence ratio = 5.2%), followed by vascular dementia (2.7%). Our study confirms that AD prevalence estimate rises exponentially with age.

Prencipe M, Casini AR, Ferretti C, Lattanzio MT, Fiorelli M, Culasso F. Prevalence of dementia in an elderly rural population: effects of age, sex, and education. J Neurol Neurosurg Psychiatry. 1996 Jun;60(6):628-33.

OBJECTIVES--To estimate the prevalence of dementia in an elderly rural population and to determine the effects of age, sex, and education. METHODS--To obtain prevalence estimates of both cognitive impairment and dementia a door to door two phase population survey was carried out in three rural villages in central Italy. Of 1147 inhabitants older than 64, 968 (84.4%) completed the protocol. RESULTS--The prevalence rates (cases per 100 population over 64) were 8.0 for dementia and 27.3 for cognitive impairment. The prevalence rate for dementia did not differ between men and women (7.9 v 8.2), but increased with age (from 1.1 at age 65-69 to 34.8 at age 90-96). Subjects with less than three years of schooling had a significantly higher prevalence of dementia (14.6; 95% confidence interval (95% CI) 10.2-19.1) than subjects with three or more years of schooling (5.9; 95% CI 4.2-7.7). At the multivariate logistic analysis, the risk related with a low level of education was still present after adjustment for age and sex (OR = 2.0; 95% CI 1.2-3.3). Alzheimer's disease was diagnosed in 64% of the 78 demented patients, vascular dementia in 27%, and other dementing diseases in 9%. CONCLUSIONS--In both Alzheimer and vascular dementia subtypes, the prevalence rates did not differ between men and women, but increased with age and were higher in subjects with a low level of education.

Fratiglioni L. Epidemiology of Alzheimer's disease. Issues of etiology and validity. Acta Neurol Scand Suppl. 1993;145:1-70.

This thesis concerns the epidemiology of Alzheimer's disease (AD) and some aspects of the validity of such studies. AD is a common and chronic dementing disorder among elderly people. Due to the lack of treatment and to the invalidating nature, the social impact of this disease is high in all the societies in which the proportion of elderly is increasing. Three studies on AD etiology have been performed. The first is a case-control study on early-onset AD and a wide range of putative risk factors. The cases were gathered from a clinical study on AD carried out in Italy. The information on the exposure obtained from a next-of-kin of 116 cases was compared with the information similarly collected from the next-of-kin of 116 hospital and 97 population controls. The other two etiological studies deal with late-onset AD and are a prevalence study on sociodemographic variables and a case-control study on selected putative risk factors. These two studies were performed within a population-based study on ageing and dementia that is ongoing in Stockholm, Sweden. The study on sociodemographic variables included 116 AD cases among 1810 people. The case-control study compared the information obtained by the informants of 98 AD cases and 266 controls. The main results of these three investigations are: (1) The prevalence of AD increases with age, even in advanced ages. (2) The prevalence of AD does not vary by gender and education. (3) The main risk factor for both early- and late-onset AD is the familial aggregation of dementia (relative risk of 2.6 and 3.2, respectively). (4) A second risk factor for early-onset AD may be the advanced age of the mother at index delivery, but this result needs confirmation. No other risk factors reported by others emerged in our study. (5) High relative risks were found for alcohol consumption and manual work in late-onset AD. Manual work could be an indicator of occupational exposures as well as life conditions or life habits. Although both these results may be affected by bias, the results are provocative for future research. Three validation studies were carried out on three different aspects: diagnosis, case ascertainment, and exposure assessment. The first study investigated the reproducibility of AD diagnosis according to the DSM-III-R diagnostic criteria. The diagnoses made by the examining physicians were compared with the diagnosis made independently by another clinician on the subjects' clinical records.

Bettini R, Gobbi G, Landonio M, Vezzetti V. [Epidemiology of pathological cerebral impairment] Clin Ter. 1992 Mar;140(3):225-33.

Among the over-65 aged patients of our division (848 in all), during a period of little more than a year, we wanted to determine the prevalence of dementia in absolute and per cent terms, using two neuropsychological tests for the evaluation of mental functions, estimating the most frequent forms according to their nature, referring to sex, considering different age groups and trying to find a connection with the pathologies that caused hospitalization and with particular social-environmental conditions. We attended also to the present therapeutical proposals and to the difficult problem of nursing demented people. We estimated the presence of a pathological cerebral impairment in 4% of the over-65 aged population; the prevalence reaches 3.5% in the group between 65 and 74 years and 12% in the one from 75 up to 80 years and over. 50% of dementia is due to Alzheimer's disease, which is more frequent among women, 26.5% to multi-infarction dementia (MID), which strikes more men, and 20.6% to a mixed form, degenerative and vascular; finally other pathologies can be responsible for dementia in the remaining percentage. It is difficult to find a certain relation between dementia and associated diseases, except for MID, which is clearly connected with cerebrovascular and cardiovascular disorders, as well as to consider particular social-environmental conditions as predisposing factors for cognitive impairment. At present, there is no way to remove causes of primary dementia with any kind of therapy, which is therefore only symptomatic. Families bear most of the burden of caring for patients. Most of Alzheimer victims remain at home and subject caregivers to prolonged emotional and physical stress, making them the "hidden victims" of the disease. Clearly, there is a desperate need for day-care help and nursing home-care facilities to make the final institutionalization less frequent or at least to delay it as much as possible.

Rocca WA, Bonaiuto S, Lippi A, Luciani P, Turtù F, Cavarzeran F, Amaducci L. Prevalence of clinically diagnosed Alzheimer's disease and other dementing disorders: a door-to-door survey in Appignano, Macerata Province, Italy. Neurology. 1990 Apr;40(4):626-31.

The purpose of this study was to investigate the prevalence of dementia in an Italian population using a door-to-door 2-phase design. As part of a social and health survey, we administered the Hodkinson abbreviated mental test to all persons over age 59 residing in the Commune of Appignano on January 1, 1987 (N = 778). We then investigated all subjects scoring 7 or less on the cognitive test following a standardized diagnostic protocol. We found 48 patients affected by dementia, yielding a crude prevalence ratio (cases per 100 population over age 59) of 6.2; prevalence ratios were 2.6 for Alzheimer's disease, 2.2 for multi-infarct dementia, 0.8 for mixed dementia, 0.4 for secondary dementia, and 0.3 for unspecified dementia. Age- and sex-specific prevalence ratios increased steeply with age and were consistently higher in women for Alzheimer's disease and in men for dementia of all types and multi-infarct dementia. Alzheimer's disease was slightly more frequent than multi-infarct dementia; however, the most common type of dementia varied across age groups. Most cases of Alzheimer's disease were sporadic and had a late age of onset. Comparison with other populations suggests that dementia of all types is as frequent in Appignano as elsewhere, and that Alzheimer's disease might be more frequent in rural than in urban populations.

Cavallo MC, Fattore G. The economic and social burden of Alzheimer disease on families in the Lombardy region of Italy. Alzheimer Dis Assoc Disord. 1997 Dec;11(4):184-90.

The purpose of this study was to measure resource consumption associated with the provision of nonmedical care to noninstitutionalized patients with Alzheimer disease (AD) residing in the Lombardy Region of Italy. A questionnaire was mailed to 1,501 caregivers who sought advice from the "Federation Alzheimer Italia" in 1995. On the basis of 616 returned questionnaires, the authors estimated that a patient with AD requires 18 hours per week of paid nonmedical services and 45 hours per week of personal care provided by a primary caregiver. Primary caregivers are more likely to be women, spouses, and retired. Almost 7 of 10 patients are supported by at least a second caregiver. Annual expenditure for nonmedical cost per patient with AD is estimated to be L 13,388,000 (U.S. $8,218). Using the replacement cost approach, the authors estimated the economic cost of informal (unpaid) care to be L 72,877,000 (U.S. $44,736). Despite some limitations in the design of the survey, this first Italian study on primary data highlights the impressive economic burden of AD on families. It also shows that AD puts many Italian families at great financial risk. Adequate and timely funding arrangements should be urgently found to make resources available to future generations of patients.