One man and his dog: Umberto D  Poverty is bad for the health of older people, as for others. It may be particularly bad for mental health and, while obviously not the only factor, changes in poverty rates have been strongly associated with the rising suicide rates in the United States (and falling global rates worldwide) in recent years [1, 2]. Loss of dignity is among the most harmful characteristics of poverty. Owning a pet may be good for the mental health of, and protective against loneliness in, older people [3]. These are among the many issues beautifully dramatized in Vittorio De Sica’s 1952 film Umberto D. The story is simple. Umberto Domenico Ferrari is a retired civil servant living on a meagre pension in a shabby, rented room in Rome. He desperately needs money to avoid eviction by his unpleasant landlady. In the meantime, she rents his room out during the day to amorous couples. His only friend is Maria, the young maid in the house, who is also in trouble: she is secretly pregnant and can persuade neither of the putative fathers to support her. Umberto’s main source of joy is his dog Flike—“a mutt with intelligent eyes”—and much of the film revolves around their relationship. With others he can be formal and irascible, but with Flike Umberto is a different man, happy to play with a ball and stick on the floor. The film follows Umberto as he tries to raise money. Not really ill, he inveigles his way into hospital for a few days to be fed for free. His few valuables prove almost worthless. When he approaches his former colleagues (although, characteristically, he cannot bring himself to ask directly for money), their superficial bonhomie cannot disguise a lack of interest in his troubles. In one of the most touching scenes, he holds out his hand palm-up to beg. However, when a passer-by seems about to give him something, he hastily turns his hand over to appear as if checking for rain. As his options dwindle and his humiliations mount, Umberto tells Maria that he is tired of everything and arrives at the idea of suicide. However, Flike has to be taken care of first. Umberto does not trust the couple willing to take the dog, at a price, to provide good care. He tries to get a little girl who plays with Flike in the park to take him, but her parents will not allow it. The dog finds him when he runs away and hides in the bushes. Finally, Umberto decides they should die together and takes Flike in his arms to stand in the path of an incoming train. However, Flike is frightened and wriggles away, and Umberto follows him. The film ends with Umberto playing with Flike on the grass as he tries to comfort the dog and regain its trust. Umberto D is one of the classics of post-war Italian neorealism. Like other such films, it was shot on location, mainly featured non-actors and aimed to reflect the reality of life for ordinary people. De Sica avoids sentimentality (always a risk in a film with a cute dog), and much of the power of the movie comes from how understated it is. In one scene, the camera just follows the maid as she does her work in the kitchen. After a few minutes, she stops, pats her pregnant belly and tears roll down her face. The final scenes may be contrived, but this is no happy ending, more a moment of reprieve, for Umberto. Umberto is a complex character. Although viewers come to care for him, he is not looking for sympathy. He is self-reliant and pernickety. (When police break up a protest march by older people seeking a raise in their pensions, his response is to blame the organizers: “They didn’t even get a permit”). He is socially isolated, but it seems primarily by choice. He is kind to and concerned about Maria. It is the threat to his dignity and self-respect, and the repeated humiliations he is subject to, that, more than just lack of money, cause him to consider suicide. Although Umberto D was critically lauded abroad, it was a flop in Italy and was attacked by politicians from all sides. Giulio Andreotti (later many-times Prime Minister of Italy) accused De Sica of “washing Italy’s dirty linen in public”. Others criticized him for focussing on human failings rather than economic conditions as the source of Umberto’s troubles [4]. There is some truth in this argument, but De Sica was not making a ‘message’ film calling for higher pensions for older people. He dedicated the film to his father, also Umberto, whom he later described as “an old bourgeois who fought against poverty and to maintain his dignity” [5]. The film reflects this and honours his father. Umberto D was played by Carlo Battisti, then 70, a former professor of linguistics in Florence. It is a superb performance from Battisti who had never acted before and who conveys a mixture of dignity and weariness with wonderfully expressive eyes. (The dog—somewhat of a canine ham—was one of the few professionals in the cast). Battisti did have plenty of life experience to draw on: he had been wounded in World War 1, captured by the Russians and sent to Siberia, during which time his only child died; and he was deported to Germany towards the end of World War 2. Battisti’s life after making the film carries a final gerontological message. The common and superficial description of him by film critics as ‘retired’ seems unjust. Instead, he went on to write, as a linguist, about the language of film and to direct a documentary about Ladin culture. He continued to work, and to publish prolifically, on the dialects of his native South Tyrol right up to his death, after a sudden illness, aged 95 in 1977. One might hope that Umberto D had as fulfilling a destiny.

Betahistine-associated anticholinergic activity-type side effects

Delirium screening in an acute geriatric ward by nurses using 4AT: results from a quality improvement project Key summary points Aim We aimed to describe the prevalence and duration of delirium, and to evaluate the test accuracy of the delirium screening tool 4AT performed by nurses in an acute geriatric ward. Findings The prevalence of delirium in old, frail medical patients was 36%, two out of three patients recovered from their delirium within 4 days after onset. The sensitivity of 4AT performed by nurses was lower than in previous studies where 4AT has been undertaken by experienced geriatricians or delirium researchers. Message A thorough training of the staff might be required before the implementation of delirium screening with 4AT in a real-life clinical setting.

Withholding cardiac defibrillators from elderly patients: evidence-based decision or ageism?

Which swallowing difficulty of food consistency is best predictor for oropharyngeal dysphagia risk in older person? Key summary points Aim Our aim was to investigate which swallowing difficulty of food consistency in older people who did not have any disease that might affect swallowing functions, and which symptoms were most likely related to oropharyngeal dysphagia (OD) risk. Findings We have found that the eating/drinking difficulty of thick liquids was the highest predictive value with respect to OD risk and the eating difficulty of mixed content food had the highest diagnostic ratio. Message The present study reports that even in older person who do not go to the hospital with the complaints of swallowing difficulty, the difficulty of swallowing thick liquids and especially the mixed content food should be questioned.

Effect of early versus delayed mobilization by physical therapists on oral intake in patients with sarcopenic dysphagia after pneumonia Key Summary Points Aim To test the hypothesis that early mobilization by physical therapists enhances oral intake after pneumonia in sarcopenic dysphagia. Findings The study demonstrated that early mobilization by a physical therapist is associated with improved total oral intake in patients with sarcopenic dysphagia after pneumonia. Message Early mobilization is possibly a practicable alternative for improving the quality of geriatric medical practice in managing pneumonia patients with sarcopenic dysphagia.

Serum creatinine and cystatin C-based index can be a screening biomarker for sarcopenia in older population Key summary points Aim To use an index based on blood biomarkers (serum creatinine and cystatin c) to screen sarcopenia in older adults. Findings Lower value of Biochemical Total Body Muscle mass index (TBMM) (calculated from serum creatinine and cystatin C) was significantly associated with higher risk of sarcopenia. Message Biochemical Total Body Muscle Mass index based on serum creatinine and cystatin C can be used to screen sarcopenia in older people.

Which laboratory malnutrition markers best predict 1-year mortality in hospitalized older adults? Key summery points Aim To study which laboratory malnutrition markers best predict 1-year mortality in hospitalized older adults as well as among patients at risk for malnutrition. Findings Low albumin serum levels best predict 1-year mortality in hospitalized older adults as well as among patients at risk for malnutrition, followed by low transferrin serum levels. Message Together with low albumin serum levels, low transferrin serum levels also predict mortality in hospitalized older adults.

Association between quantitative bone ultrasound and self-reported physical activity in nursing homes residents Key summary points Aim To determine the prevalence and risk factors for osteoporosis in persons over 65 who live in nursing homes. Findings The prevalence of osteoporosis among residents in nursing homes, based on QUS bone measurements and defined as QUI-T score ≤ − 2.2, was 51.9% in women and 8.5% in men. Physical activity was a more important factor for preserving bone health than calcium intake. Message Regular screening for osteoporosis, together with nutrition assessment and physical activity promotion, should be implemented in nursing home settings.

Efficacy of fluoroscopy-guided triple shoulder injection for older patients with nonspecific shoulder pain Key Summary Points Aim The study was to evaluate the effects of fluoroscopy-guided triple shoulder injection (i.e. injection into glenohumeral joint, subacromial space, and acromioclavicular joint) on pain and function in older patients with nonspecific shoulder pain. Findings A significant improvement was detected in pain, and function at 3 and 12 weeks after injection compared with baseline. Message Fluoroscopy-guided triple shoulder injection offers a therapeutic option for older patients with nonspecific shoulder pain.