Primary prevention: do the very elderly require a different approach?

Development and validation of a life expectancy estimator for multimorbid older adults: a cohort study protocol

BACKGROUND

Older multimorbid adults have a high risk of mortality and a short life expectancy (LE). Providing high-value care and avoiding care overuse, including of preventive care, is a serious challenge among multimorbid patients. While guidelines recommend to tailor preventive care according to the estimated LE, there is no tool to estimate LE in this specific population. Our objective is therefore to develop an LE estimator for older multimorbid adults by transforming a mortality prognostic index, which will be developed and internally validated in a prospective cohort.

METHODS AND ANALYSIS

We will analyse data of the Optimising Therapy to Prevent Avoidable Hospital Admissions in Multimorbid Older People cohort study in Bern, Switzerland. 822 participants were included at hospitalisation with age of 70 years or older, multimorbidity (three or more chronic medical conditions) and polypharmacy (use of five drugs or more for >30 days). All-cause mortality will be assessed during 3 years of follow-up. We will apply a flexible parametric survival model with backward stepwise selection to identify the mortality risk predictors. The model will be internally validated using bootstrapping techniques. We will derive a point-based risk score from the regression coefficients. We will transform the 3-year mortality prognostic index into an LE estimator using the Gompertz survival function. We will perform a qualitative assessment of the clinical usability of the LE estimator and its application. We will conduct the development and validation of the mortality prognostic index following the Prognosis Research Strategy (PROGRESS) framework and report it following the Transparent Reporting of a Multivariable Prediction Model for Individual Prognosis or Diagnosis (TRIPOD) statement.

ETHICS AND DISSEMINATION

Written informed consent by patients themselves or, in the case of cognitive impairment, by a legal representative, was required before enrolment. The local ethics committee (Kantonale Ethikkommission Bern) has approved the study. We plan to publish the results in peer-reviewed journals and present them at national and international conferences.

Ethical issues in early diagnosis and prevention of Alzheimer disease

This paper considers ethical issues related to early diagnosis and all forms of prevention of Alzheimer disease and related conditions. It offers a critical view of the current state of scientific, clinical, and social responses to the growing number of older people with cognitive challenges, and suggests how priorities going forward should be different from those receiving most attention today. We begin with a review of global policy efforts, consider the fundamental goals of prevention, examine issues surrounding early diagnosis, explore more deeply values associated with efforts to prevent age associated cognitive decline, and conclude by considering often unexplored ethical issues that contextualize the field and should influence our approaches to the future.

Quality of prescribing predicts hospitalisation in octogenarians: life and living in advanced age: a cohort study in New Zealand (LiLACS NZ)

BACKGROUND

Prescribing for older people is complex, and many studies have highlighted that appropriate prescribing in this cohort is not always achieved. However, the long-term effect of inappropriate prescribing on outcomes such as hospitalisation and mortality has not been demonstrated. The aim of this study was to determine the level of potentially inappropriate prescribing (PIP) for participants of the Life and Living in Advanced Age: A Cohort Study in New Zealand (LiLACS NZ) study at baseline and examine the association between PIP and hospitalisation and mortality at 12-months follow-up.

METHODS

PIP was determined using STOPP/START. STOPP identified potentially inappropriate medicines (PIMs) prescribed, START identified potential prescribing omissions (PPOs). STOPP/START were applied to all LiLACS NZ study participants, a longitudinal study of ageing, which includes 421 Māori aged 80-90 years and 516 non-Māori aged 85 years. Participants' details (e.g. age, sex, living arrangements, socioeconomic status, physical functioning, medical conditions) were gathered by trained interviewers. Some participants completed a core questionnaire only, which did not include medications details. Medical conditions were established from a combination of self-report, review of hospital discharge and general practitioner records. Binary logistic regression, controlled for multiple potential confounders, was conducted to determine if either PIMs or PPOs were associated with hospital admissions and mortality (p < 0.05 was considered significant).

RESULTS

Full data were obtained for 267 Māori and 404 non-Māori. The mean age for Māori was 82.3(±2.6) years, and 84.6(±0.53) years for non-Māori. 247 potentially inappropriate medicines were identified, affecting 24.3% Māori and 28.0% non-Māori. PIMs were not associated with 12-month mortality or hospitalisation for either cohort (p > 0.05; adjusted models). 590 potential prescribing omissions were identified, affecting 58.1% Māori and 49.0% non-Māori. PPOs were associated with hospitalisation (p = 0.001 for Māori), but were not associated with risk of mortality (p > 0.05) for either cohort within the 12-month follow-up (adjusted models).

CONCLUSION

PPOs were more common than PIMs and were associated with an increased risk of hospitalisation for Māori. This study highlights the importance of carefully considering all indicated medicines when deciding what to prescribe. Further follow-up is necessary to determine the long-term effects of PIP on mortality and hospitalisation.

Antihypertensive Treatment Patterns and Blood Pressure Control in Older Adults: Results from the Berlin Aging Study II

BACKGROUND

Hypertension is highly prevalent in older adults and represents a major public health issue since recognition, awareness, treatment and control are insufficient. Analyses of prescription patterns in conjunction with clinical parameters can provide novel insights into the current practice of hypertension management and help to identify barriers to sufficient hypertension control.

METHODS

A cross-sectional analysis was conducted. Prevalence of hypertension, patterns of antihypertensive therapy, and determinants of blood pressure (BP) control were examined in the Berlin Aging Study II cohort, including 1654 community-dwelling older adults (60-85 years of age).

RESULTS

Of the participants, 75.9% had hypertension; 40.6% of these were not prescribed BP medications. Lack of hypertension awareness, younger age, absence of comorbidities, not being on a statin, and not having visited a physician in the past 3 months were associated with lack of treatment. Forty-two percent of treated hypertensive individuals received monotherapy and 58.0% received combination therapy. Renin-angiotensin-aldosterone system (RAAS) inhibitors, and β-blockers were most commonly prescribed, while calcium channel blockers were least prescribed. Only 38.5% of treated hypertensive individuals had their BP controlled to < 140/90 mmHg. Number and choice of BP medications were not predictive of BP control; neither were age, glycated hemoglobin (HbA_1c), kidney function, or number of healthcare visits. However, female sex, lower low-density lipoprotein cholesterol (LDL-C) levels and current smoking, amongst others, were positively associated with BP control. There was evidence of significant effect modification by statins in the association of LDL-C and BP.

CONCLUSION

The majority of older adults do not reach BP goals. Antihypertensive prescription patterns do not conform to current guidelines. Using more BP medications was not associated with higher odds of BP control. Lowering LDL-C might be favorable in terms of BP control.

Primary Prevention of Cardiovascular Risk in Octogenarians by Risk Factors Control

Primary prevention of cardiovascular events in older adults is a relevant problem, due to lack of evidence for safe and efficacious therapy, its costs and elderly quality of life, Italy's aging population is constantly increasing, so cardiovascular disease (CVD) primary prevention in the elderly is a prime objective. Life expectancy has dramatically increased over the last 2 decades, the proportion of individuals aged 80 years and older has grown rapidly in Europe and the United States, but cost / effective ratio of CVD prevention through risk factors control is debated. It is therefore important to implement cardiovascular risk factors estimation in the elderly to maximize the quality of life of patients and to lengthen their healthy life expectancy, choosing the better treatment for each patient sharing the choice with himself when it is possible, always remembering that elderly patients often have multiple co-morbidities that require a high number of concurrent medications; this may increase the risk for drug-drug interactions, thereby reducing the potential benefits of CVD prevention therapy. Nevertheless, CVD is not an inevitable concomitant of aging. Sometimes, autopsy in the elderly reveals atheroma-free coronary arteries, a normal-sized heart and unscarred valves. All primary prevention strategy decisions should consider estimated life expectancy and overall function and not just the cardiovascular event risks, magnitude and time to benefit or harm, potentially altered adverse effect profiles, and informed patient preferences. CVD primary prevention needs to be more implemented in the elderly, this might contribute to improve health status and quality of life in this growing population if correctly performed.

Appropriateness of statin prescription in the elderly

Statins, the most widely used drugs in the Western world, have become a pivotal component in the primary and secondary prevention of vascular diseases. Although benefits have been well documented in younger-than-75-year-old individuals, the value of statins in people aged >75years and over is controversial. The CTT meta-analysis calculated an absolute risk reduction of 0.6%/year per 38.7mg/dl reduction in LDL-C levels in patients aged >75years, that would translate into a number needed to treat of 167. However, the absolute effect of a 38.7mg/dl cholesterol lowering on the rate of annual ischemic heart disease mortality is 10-fold larger in older vs younger patients. In order to advise physician prescription, three major Guidelines have been published over the last few years, i.e. the AHA/ACC and the NLA in the US, and the ESC/EAS in Europe. Moreover, statin prescription in the elderly should also consider the cardiovascular outcomes of elderly patients reported in classical statin preventive trials which give important clues on adherence and persistence of use, as well as on drug safety. The present review discusses benefits of intensive vs moderate statin therapy, justifications for the use of aggressive lipid management in the very old and the use of statins in frail elderlies. The final decision on the therapeutic strategy with statins in elderlies at higher risk to develop cardiovascular events should be always based on a careful analysis of the patient's general health and on the presence of metabolic abnormalities or drug interactions potentially leading to risk.

Individualizing Prevention for Older Adults

Prevention can help older adults avoid illness by identifying and addressing conditions before they cause symptoms, but prevention can also harm older adults if conditions that are unlikely to cause symptoms in the individual's lifetime are identified and treated. To identify older adults who preventive interventions are most likely to benefit (and most likely to harm), we propose a framework that compares an individual's life expectancy (LE) with the time to benefit (TTB) for an intervention. If LE is less than the TTB, the individual is unlikely to benefit but is exposed to the risks of the intervention, and the intervention should generally NOT be recommended. If LE is longer than the TTB, the individual could benefit, and the intervention should generally be recommended. If LE is similar to the TTB, the individual's values and preferences should be the major determinant of the decision. To facilitate the use of this framework in routine clinical care, we explored ways to estimate LE, identified the TTB for common preventive interventions, and developed strategies for communicating with individuals. We have synthesized these strategies and demonstrate how they can be used to individualize prevention for a hypothetical beneficiary in the setting of a Medicare annual wellness visit. Finally, we place prevention in the context of curative and symptom-oriented care and outline how prevention should be focused on healthier older adults, whereas symptom-oriented care should predominate in sicker older adults.

Effects of Three Different Chair-Based Exercise Programs on People Older Than 80 Years

This study aimed at comparing the effects of three chair-based exercise programs on people older than 80 years. Thirty-six participants (87.91 ± 4.70 years) were randomly allocated to an aerobic, muscular resistance, or joint mobility exercise program. The participants exercised 3 days per week during 3 months. A hand-held dynamometer, the Tinetti Gait Balance, the Barthel Index, and the Timed Up and Go Test (TUG) (assessed by means of the Wiva^® science sensor) were used to evaluate the effects of the programs on the participants' strength, balance, functional independence, and functional mobility, respectively. After the intervention, it was observed that only the elastic-band program resulted in significant improvements in strength and balance. These results imply that when choosing a low-cost exercise program for very old people, the use of elastic bands stands as a far better option than pedaling on a pedal exerciser or performing mobility exercises.

2017 Position Paper of the Italian Society for Cardiovascular Prevention (SIPREC) for an Updated Clinical Management of Hypercholesterolemia and Cardiovascular Risk: Executive Document

The benefits achieved by implementing cardiovascular prevention strategies in terms of reduced incidence of atherosclerotic diseases and mortality are accepted, worldwide. In particular, the clinical management of hypercholesterolemia has a fundamental role for all preventive strategies, both in primary and secondary prevention, at each stage of cardiovascular risk. Since the net clinical benefit of lipid-lowering therapy largely depends on baseline individual cardiovascular risk profile, the assessment of individual risk is essential to establish type and intensity of both preventive and therapeutic strategies. Thus, the real challenge in a setting of clinical practice is not only to identify whom to treat among individuals at low-to-moderate risk, but mostly how much and how long to treat high or very-high risk patients. This manuscript, which reflects concepts and positions that have been published in a more extensive document of the Italian Society for Cardiovascular Prevention (SIPREC), deals with the diagnostic and therapeutic management of patients with dyslipidaemia, with an evidence-based approach adapted and updated from recent guidelines of the European Society of Cardiology and very recent results of randomized clinical trials. The purpose is to suggest a multidimensional and integrated actions aimed at eliminating or minimizing the impact of cardiovascular diseases and their related disabilities and mortality in patients with hypercholesterolemia.

Renal Insufficiency and Medication in Nursing Home Residents. A Cross-Sectional Study (IMREN)

BACKGROUND

Nursing home residents often suffer from a multiplicity of medical conditions and take many different drugs. Many drugs are eliminated via the kidneys and thus require dose adjustment in patients with renal insufficiency. This is the first study to address the prevalence of renal insufficiency among nursing home residents in Germany, and the extent to which such persons take drugs that are contraindicated or incorrectly dosed because of renal insufficiency.

METHODS

We carried out a cross-sectional study in nursing homes in the German regions of Bremen and Lower Saxony. Data were collected by nursing staff and given to us anonymously. Whenever the nursing home data did not include a current creatinine value, the patient's general practitioner was asked to supply this value. The estimated creatinine clearance (eCCr) was calculated with the Cockcroft-Gault formula.

RESULTS

852 residents of 21 nursing homes were included in the study; eCCr values were obtainable for 685 (80.4%) of them (average age, 83.3 years; 75.2% female). 48.2% of these patients (95% confidence interval [CI] 41.8-54.5) had moderate renal insufficiency (eCCr 59-30 mL/min), and 15.5% (95% CI 12.4-18.6) had severe renal insufficiency (eCCr <30 mL/min). 19.7% were regularly taking at least one medication that was contraindicated or incorrectly dosed in the light of renal insufficiency. Predictors for such inappropriate drug use were advanced age, female sex, arterial hypertension, and polypharmacy. The drugs that were most often inappropriately used were metformin, ramipril, and potassium chloride.

CONCLUSION

Nursing home residents often suffer from renal insufficiency and should therefore have their creatinine levels measured regularly. A knowledge of the creatinine level is a prerequisite for the proper adjustment of drug doses (if necessary). A practical and compact summary of dose-adjustment recommendations for patients with renal insufficiency would be desirable but is not yet available.

Hypertension and aging

Hypertension is a highly prevalent condition with numerous health risks, and the incidence of hypertension is greatest among older adults. Traditional discussions of hypertension have largely focused on the risks for cardiovascular disease and associated events. However, there are a number of collateral effects, including risks for dementia, physical disability, and falls/fractures which are increasingly garnering attention in the hypertension literature. Several key mechanisms--including inflammation, oxidative stress, and endothelial dysfunction--are common to biologic aging and hypertension development and appear to have key mechanistic roles in the development of the cardiovascular and collateral risks of late-life hypertension. The objective of the present review is to highlight the multi-dimensional risks of hypertension among older adults and discuss potential strategies for treatment and future areas of research for improving overall care for older adults with hypertension.

[Counseling and preventive action in elderly population in hospitals and residences in Spain]

Objetivos

Conocer el perfil sociosanitario de los pacientes mayores atendidos en consultas; conocer las acciones preventivas que se llevan a cabo, de forma rutinaria, en hospitales, residencias geriátricas y otros centros asistenciales en España.

Diseño

Estudio descriptivo transversal, basado en un cuestionario a médicos que atienden a población mayor de 65 años en España (2013).

Emplazamiento

Centros de diferentes comunidades autónomas en España.

Participantes: Un total de 420 médicos de hospitales, residencias y otros centros. Se obtuvieron datos de 840 consultas a pacientes geriátricos.

Mediciones principales

Variables principales de resultados: dependencia, comorbilidad, motivo de consulta, actuación en consulta y recomendación de estilos de vida saludable. Factor asociado, tipo de institución en la que se atendió al paciente. Análisis de prevalencias y diferencias con Chi-cuadrado.

Resultados

El 66,7% presentaban dependencia, siendo mayor entre las mujeres: 68,9% vs 62,4% (p = 0,055). El 88,6% de mujeres atendidas con 85 o más años presentaban comorbilidad, mientras que en hombres de ese mismo grupo de edad eran un 79,8%. Solo un 6,6% de pacientes con comorbilidad recibieron recomendaciones saludables durante la consulta. El 79,6% de pacientes atendidos en hospitales recibieron recomendaciones de estilo de vida saludable, mientras que en las residencias geriátricas las recibieron el 59,62% de los pacientes (p < 0,001).

Conclusiones

Se detecta una escasa acción preventiva y de promoción de la salud hacia las personas mayores, con diferencias entre hospitales y residencias geriátricas. Parece necesario incentivar la actitud promotora de salud y las intervenciones preventivas en la práctica clínica gerontológica.

Dietary Patterns High in Red Meat, Potato, Gravy, and Butter Are Associated with Poor Cognitive Functioning but Not with Rate of Cognitive Decline in Very Old Adults

BACKGROUND

Healthy dietary patterns (DPs) have been linked to better cognition and reduced risk of dementia in older adults, but their role in cognitive functioning and decline in the very old (aged ≥85 y) is unknown.

OBJECTIVE

We investigated the association between previously established DPs from the Newcastle 85+ Study and global and attention-specific cognition over 5 y.

METHODS

We followed up with 302 men and 489 women (1921 birth cohort from Northeast United Kingdom) for change in global cognition [measured by the Standardized Mini-Mental State Examination (SMMSE)] over 5 y and attention (assessed by the cognitive drug research attention battery) over 3 y. We used 2-step clustering to derive DPs and mixed models to determine the relation between DPs and cognition in the presence of the dementia susceptibility gene.

RESULTS

Previously, we characterized 3 DPs that differed in intake of red meat, potato, gravy, and butter and varied with key health measures. When compared with participants in DP1 (high red meat) and DP3 (high butter), participants in DP2 (low meat) had higher SMMSE scores at baseline (P < 0.001) and follow-ups, and better initial attention (P < 0.05). Membership in DP1 and DP3 was associated with overall worse SMMSE scores (β = 0.09, P = 0.01 and β = 0.08, P = 0.02, respectively) than membership in DP2 after adjustment for sociodemographic factors, lifestyle, multimorbidity, and body mass index (BMI). Additional adjustment for apolipoprotein (apoE) ε4 genotype attenuated the association to nonsignificant in women but not in men in DP1 (β = 0.13, P = 0.02). Participants in DP1 and DP3 also had overall worse concentration (β = 0.04, P = 0.002 and β = 0.028, P = 0.03, respectively) and focused attention (β = 0.02, P = 0.01 and β = 0.02, P = 0.03, respectively), irrespective of apoE ε4 genotype, but similar rate of decline in all cognitive measures over time.

CONCLUSION

DPs high in red meat, potato, gravy (DP1), or butter (DP3) were associated with poor cognition but not with the rate of cognitive decline in very old adults.

Statins for primary cardiovascular prevention in the elderly

The elderly population is increasing worldwide, with subjects > 65 years of age constituting the fastest-growing age group. Furthermore, the elderly face the greatest risk and burden of cardiovascular disease mortality and morbidity. Although elderly patients, particularly those older > 75, have not been well represented in randomized clinical trials evaluating lipid-lowering therapy, the available evidence supporting the use of statin therapy in primary prevention in older individuals is derived mainly from subgroup analyses and post-hoc data. On the other hand, elderly patients often have multiple co-morbidities that require a high number of concurrent medications; this may increase the risk for drug-drug interactions, thereby reducing the potential benefits of statin therapy. The aim of this review was to present the relevant literature regarding statin use in the elderly for their primary cardiovascular disease, with the associated risks and benefits of treatment.