Multifactorial cardiovascular disease prevention in patients aged 75 years and older: A randomized controlled trial: Drugs and Evidence Based Medicine in the Elderly (DEBATE) Study

Interventions for improving modifiable risk factor control in the secondary prevention of stroke

BACKGROUND

People with stroke or transient ischaemic attack (TIA) are at increased risk of future stroke and other cardiovascular events. Stroke services need to be configured to maximise the adoption of evidence-based strategies for secondary stroke prevention. Smoking-related interventions were examined in a separate review so were not considered in this review. This is an update of our 2014 review.

OBJECTIVES

To assess the effects of stroke service interventions for implementing secondary stroke prevention strategies on modifiable risk factor control, including patient adherence to prescribed medications, and the occurrence of secondary cardiovascular events.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (April 2017), the Cochrane Effective Practice and Organisation of Care Group Trials Register (April 2017), CENTRAL (the Cochrane Library 2017, issue 3), MEDLINE (1950 to April 2017), Embase (1981 to April 2017) and 10 additional databases including clinical trials registers. We located further studies by searching reference lists of articles and contacting authors of included studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that evaluated the effects of organisational or educational and behavioural interventions (compared with usual care) on modifiable risk factor control for secondary stroke prevention.

DATA COLLECTION AND ANALYSIS

Four review authors selected studies for inclusion and independently extracted data. The quality of the evidence as 'high', 'moderate', 'low' or 'very low' according to the GRADE approach (GRADEpro GDT).Three review authors assessed the risk of bias for the included studies. We sought missing data from trialists.The results are presented in 'Summary of findings' tables.

MAIN RESULTS

The updated review included 16 new studies involving 25,819 participants, resulting in a total of 42 studies including 33,840 participants. We used the Cochrane risk of bias tool and assessed three studies at high risk of bias; the remainder were considered to have a low risk of bias. We included 26 studies that predominantly evaluated organisational interventions and 16 that evaluated educational and behavioural interventions for participants. We pooled results where appropriate, although some clinical and methodological heterogeneity was present.Educational and behavioural interventions showed no clear differences on any of the review outcomes, which include mean systolic and diastolic blood pressure, mean body mass index, achievement of HbA1c target, lipid profile, mean HbA1c level, medication adherence, or recurrent cardiovascular events. There was moderate-quality evidence that organisational interventions resulted in improved blood pressure control, in particular an improvement in achieving target blood pressure (odds ratio (OR) 1.44, 95% confidence interval (CI) 1.09 to1.90; 13 studies; 23,631 participants). However, there were no significant changes in mean systolic blood pressure (mean difference (MD), -1.58 mmHg 95% CI -4.66 to 1.51; 16 studies; 17,490 participants) and mean diastolic blood pressure (MD -0.91 mmHg 95% CI -2.75 to 0.93; 14 studies; 17,178 participants). There were no significant changes in the remaining review outcomes.

AUTHORS' CONCLUSIONS

We found that organisational interventions may be associated with an improvement in achieving blood pressure target but we did not find any clear evidence that these interventions improve other modifiable risk factors (lipid profile, HbA1c, medication adherence) or reduce the incidence of recurrent cardiovascular events. Interventions, including patient education alone, did not lead to improvements in modifiable risk factor control or the prevention of recurrent cardiovascular events.

Health-related quality of life as a predictor of mortality in heterogeneous samples of older adults

BACKGROUND

Health-related quality of life (HRQoL) is associated with survival in older people with multimorbidities and disabilities. However, older people differ in their characteristics, and less is known about whether HRQoL predicts survival in heterogeneous older population samples differing in their functional, cognitive, psychological or social disabilities. The aim of this study was to explore HRQoL in heterogeneous samples of older men and women, and to explore its prognostic significance for mortality.

METHODS

We analysed combined individual patient data from eight heterogeneous study samples all of which were assessed with the same methods. We used 15D, a generic, comprehensive instrument for measuring HRQoL, which provides a single index in addition to a profile. Two-year mortality was retrieved from central registers.

RESULTS

Health-related quality of life measurements with 15D were available for 3153 older adults. The mean HRQoL was highest among older businessmen (0.878) and lowest among nursing home residents (0.601). 15D predicted independently and significantly the 2-year survival in the total sample [hazard ratio (HR)/SD 0.44, 95% CI 0.40-0.48)]. However, 15D did not predict mortality in samples of spousal caregivers, lonely older adults and cardiovascular patients.

CONCLUSIONS

15D captures health and disability factors associated with prognosis whereas in older populations suffering from psychological and social impairments such as caregiver burden or loneliness HRQoL may not reflect their health risks.

Experimental designs for multicomponent interventions among persons with multifactorial geriatric syndromes

This paper discusses issues about the design of clinical trials to test multicomponent interventions for multifactorial health conditions, such as geriatric syndromes in which more than one risk factor is related to the outcome. The issues covered include: identification and selection of modifiable risk factors related to the outcome of interest, selection of intervention components to reduce the deleterious effects of the modifiable risk factors, assignment of components of the intervention, blinding, sample size requirements and estimation of component effects. Each of these issues is explored using examples from nine illustrative multicomponent intervention trials. Statistical and clinical concerns regarding the design of multicomponent interventions are addressed. We also propose elements of multicomponent interventions for multifactorial health conditions that should be reported in publications and areas where future research is needed.

Psychosocial interventions for smoking cessation in patients with coronary heart disease

BACKGROUND

This is an update of a Cochrane review previously published in 2008. Smoking increases the risk of developing atherosclerosis but also acute thrombotic events. Quitting smoking is potentially the most effective secondary prevention measure and improves prognosis after a cardiac event, but more than half of the patients continue to smoke, and improved cessation aids are urgently required.

OBJECTIVES

This review aimed to examine the efficacy of psychosocial interventions for smoking cessation in patients with coronary heart disease in short-term (6 to 12 month follow-up) and long-term (more than 12 months). Moderators of treatment effects (i.e. intervention types, treatment dose, methodological criteria) were used for stratification.

SEARCH METHODS

The Cochrane Central Register of Controlled Trials (Issue 12, 2012), MEDLINE, EMBASE, PsycINFO and PSYNDEX were searched from the start of the database to January 2013. This is an update of the initial search in 2003. Results were supplemented by cross-checking references, and handsearches in selected journals and systematic reviews. No language restrictions were applied.

SELECTION CRITERIA

Randomised controlled trials (RCTs) in patients with CHD with a minimum follow-up of 6 months.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial eligibility and risk of bias. Abstinence rates were computed according to an intention to treat analysis if possible, or if not according to completer analysis results only. Subgroups of specific intervention strategies were analysed separately. The impact of study quality on efficacy was studied in a moderator analysis. Risk ratios (RR) were pooled using the Mantel-Haenszel and random-effects model with 95% confidence intervals (CI).

MAIN RESULTS

We found 40 RCTs meeting inclusion criteria in total (21 trials were new in this update, 5 new trials contributed to long-term results (more than 12 months)). Interventions consist of behavioural therapeutic approaches, telephone support and self-help material and were either focused on smoking cessation alone or addressed several risk factors (eg. obesity, inactivity and smoking). The trials mostly included older male patients with CHD, predominantly myocardial infarction (MI). After an initial selection of studies three trials with implausible large effects of RR > 5 which contributed to substantial heterogeneity were excluded. Overall there was a positive effect of interventions on abstinence after 6 to 12 months (risk ratio (RR) 1.22, 95% confidence interval (CI) 1.13 to 1.32, I² 54%; abstinence rate treatment group = 46%, abstinence rate control group 37.4%), but heterogeneity between trials was substantial. Studies with validated assessment of smoking status at follow-up had similar efficacy (RR 1.22, 95% CI 1.07 to 1.39) to non-validated trials (RR 1.23, 95% CI 1.12 to 1.35). Studies were stratified by intervention strategy and intensity of the intervention. Clustering reduced heterogeneity, although many trials used more than one type of intervention. The RRs for different strategies were similar (behavioural therapies RR 1.23, 95% CI 1.12 to 1.34, I² 40%; telephone support RR 1.21, 95% CI 1.12 to 1.30, I² 44%; self-help RR 1.22, 95% CI 1.12 to 1.33, I² 40%). More intense interventions (any initial contact plus follow-up over one month) showed increased quit rates (RR 1.28, 95% CI 1.17 to 1.40, I² 58%) whereas brief interventions (either one single initial contact lasting less than an hour with no follow-up, one or more contacts in total over an hour with no follow-up or any initial contact plus follow-up of less than one months) did not appear effective (RR 1.01, 95% CI 0.91 to 1.12, I² 0%). Seven trials had long-term follow-up (over 12 months), and did not show any benefits. Adverse side effects were not reported in any trial. These findings are based on studies with rather low risk of selection bias but high risk of detection bias (namely unblinded or non validated assessment of smoking status).

AUTHORS' CONCLUSIONS

Psychosocial smoking cessation interventions are effective in promoting abstinence up to 1 year, provided they are of sufficient duration. After one year, the studies showed favourable effects of smoking cessation intervention, but more studies including cost-effectiveness analyses are needed. Further studies should also analyse the additional benefit of a psychosocial intervention strategy to pharmacological therapy (e.g. nicotine replacement therapy) compared with pharmacological treatment alone and investigate economic outcomes.

Interventions for improving modifiable risk factor control in the secondary prevention of stroke

BACKGROUND

People with stroke or transient ischaemic attack (TIA) are at increased risk of future stroke and other cardiovascular events. Evidence-based strategies for secondary stroke prevention have been established. However, the implementation of prevention strategies could be improved.

OBJECTIVES

To assess the effects of stroke service interventions for implementing secondary stroke prevention strategies on modifiable risk factor control, including patient adherence to prescribed medications, and the occurrence of secondary cardiovascular events.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (April 2013), the Cochrane Effective Practice and Organisation of Care Group Trials Register (April 2013), CENTRAL (The Cochrane Library 2013, issue 3), MEDLINE (1950 to April 2013), EMBASE (1981 to April 2013) and 10 additional databases. We located further studies by searching reference lists of articles and contacting authors of included studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that evaluated the effects of organisational or educational and behavioural interventions (compared with usual care) on modifiable risk factor control for secondary stroke prevention.

DATA COLLECTION AND ANALYSIS

Two review authors selected studies for inclusion and independently extracted data. One review author assessed the risk of bias for the included studies. We sought missing data from trialists.

MAIN RESULTS

This review included 26 studies involving 8021 participants. Overall the studies were of reasonable quality, but one study was considered at high risk of bias. Fifteen studies evaluated predominantly organisational interventions and 11 studies evaluated educational and behavioural interventions for patients. Results were pooled where appropriate, although some clinical and methodological heterogeneity was present. The estimated effects of organisational interventions were compatible with improvements and no differences in the modifiable risk factors mean systolic blood pressure (mean difference (MD) -2.57 mmHg; 95% confidence interval (CI) -5.46 to 0.31), mean diastolic blood pressure (MD -0.90 mmHg; 95% CI -2.49 to 0.68), blood pressure target achievement (OR 1.24; 95% CI 0.94 to 1.64) and mean body mass index (MD -0.68 kg/m(2); 95% CI -1.46 to 0.11). There were no significant effects of organisational interventions on lipid profile, HbA1c, medication adherence or recurrent cardiovascular events. Educational and behavioural interventions were not generally associated with clear differences in any of the review outcomes, with only two exceptions.

AUTHORS' CONCLUSIONS

Pooled results indicated that educational interventions were not associated with clear differences in any of the review outcomes. The estimated effects of organisational interventions were compatible with improvements and no differences in several modifiable risk factors. We identified a large number of ongoing studies, suggesting that research in this area is increasing. The use of standardised outcome measures would facilitate the synthesis of future research findings.

Lifestyle interventions in patients with coronary heart disease: a systematic review

CONTEXT

Coronary heart disease (CHD) is responsible for about 15% of all deaths worldwide and is identified as a top priority for decision makers. Both primary and secondary prevention are considered key strategies in the prevention of CHD. The aim of this study was to assess the efficacy of nonpharmacologic interventions with multiple lifestyle components in patients with established CHD in comparison to usual care. For this reason, a systematic review and meta-analysis of RCTs were performed.

EVIDENCE ACQUISITION

The Cochrane Library, MEDLINE, and EMBASE databases were examined until March 31, 2012 (without start date) in order to identify studies addressing patient-tailored multifactorial lifestyle interventions aimed at reducing more than one cardiovascular risk factor in patients with established CHD. Primary endpoints were fatal and nonfatal cardiovascular events. Secondary outcomes were overall mortality and cardiovascular disease-associated hospital readmissions.

EVIDENCE SYNTHESIS

The search strategy yielded 14 unique RCTs, which were considered in the qualitative analysis. Nine of them contributed to the meta-analysis. A random effects model was used to pool the data. The meta-analysis showed a significant risk reduction of 18% (relative risk 0.82, 95% CI=0.69, 0.98) of fatal cardiovascular events in patients undergoing multifactorial lifestyle interventions. Further, a nonsignificant reduction of nonfatal events, overall mortality and hospital readmissions was found.

CONCLUSIONS

Multifactorial lifestyle interventions aimed at improving modifiable risk factors in patients with established CHD reduce the risk for fatal cardiovascular events. Therefore, they may have added value in secondary prevention of CHD.

Detailed cognitive function and use of drugs with anticholinergic properties in older people: a community-based cross-sectional study

BACKGROUND

Many potentially inappropriate drugs prescribed to older people have anticholinergic properties and may therefore be harmful. Drugs with anticholinergic properties (DAPs) are associated with cognitive decline.

OBJECTIVE

Our aim was to study the profile of various cognitive functions related to current use of DAPs.

METHODS

A cross-sectional study was conducted in Helsinki, Finland, and included 400 home-dwelling individuals aged 75-90 years without major clinical dementia but with a history of stable atherosclerotic disease who were participants of the DEBATE (Drugs and Evidence-Based Medicine in the Elderly) study. The cognition of the users (n = 295) and non-users (n = 105) of DAPs was measured with the Consortium to Establish a Registry for Alzheimer's Disease (CERAD) test battery.

RESULTS

Use of DAPs was statistically significantly associated with a low score in verbal fluency, in naming, and on the Mini-Mental State Examination (MMSE). In the logistic regression analysis, the difference remained for low verbal fluency (odds ratio [OR] 1.84, 95 % CI 1.02-3.32; p = 0.044) and naming (OR 1.81, 95 % CI 1.09-3.00; p = 0.021) but not for MMSE score after adjusting for age, sex and education.

CONCLUSIONS

Performances for verbal fluency and naming were poorer in DAP users than in non-users, suggesting a possible impairment of executive functioning and semantic memory. The dimensions of the CERAD test assessing episodic memory-the subtests that are the most sensitive in terms of detecting early Alzheimer's disease-did not show differences between users and non-users of DAPs.

Will-to-live and survival in a 10-year follow-up among older people

BACKGROUND

there is little research how older people's will-to-live predicts their survival.

OBJECTIVE

to investigate how many years home-dwelling older people wish to live and how this will-to-live predicts their survival.

METHODS

as a part of the Drugs and Evidence-Based Medicine in the Elderly (DEBATE) study, 400 home-dwelling individuals aged 75-90 were recruited into a cardiovascular prevention trial in Helsinki. In 2000, a questionnaire about the wishes of their remaining life was completed by 283 participants. Participants were inquired how many years they would still wish to live, and divided into three groups according to their response: group 1: wishes to live <5 years, group 2: 5-10 years, group 3: >10 years. Mortality was confirmed from central registers during a 10-year follow-up. The adjusted Cox proportional hazard model was used to determine how will-to-live predicted survival.

RESULTS

in group 1 wishing to live less than 5 years, the mean age and the Charlson comorbidity index were the highest, and subjective health the poorest. There were no differences between the groups in cognitive functioning or feeling depressed. Mortality was the highest (68.0%) among those wishing to live <5 years compared with those wishing to live 5-10 years (45.6%) or over 10 years (33.3%) (P < 0.001). With group 1 as referent (HR: 1.0) in the Cox proportional hazard model adjusting for age, gender, Charlson comorbidity index and depressive feelings, HR for mortality was 0.66 (95% CI: 0.45-0.95) (P = 0.027) and 0.47 (95% CI: 0.26-0.86) (P = 0.011) in groups 2 and 3, respectively.

CONCLUSION

the will-to-live was a strong predictor for survival among older people irrespective of age, gender and comorbidities.

Association of anticholinergic drugs with hospitalization and mortality among older cardiovascular patients: A prospective study

BACKGROUND

Many potentially inappropriate drugs prescribed to older people have anticholinergic properties as adverse effects and are therefore potentially harmful. These effects typically include constipation, dry mouth, blurred vision, dizziness and slowing of urination. It has been shown that drugs with anticholinergic properties (DAPs) are associated with cognitive decline and dementia, may contribute to events such as falls, delirium and impulsive behaviour, are associated with self-reported adverse effects and physical impairment, and may even be associated with mortality. However, studies of the prognostic implications of DAPs remain scarce.

OBJECTIVE

To evaluate the impact of DAPs on hospitalization and mortality in older patients with stable cardiovascular disease (CVD).

METHODS

This was a prospective study with a mean follow-up of 3.3 years involving two study groups: users (n = 295) and non-users (n = 105) of DAPs. The participants were 400 community-dwelling older people (aged 75-90 years) with stable CVD participating in a secondary prevention study of CVD (DEBATE) in Helsinki, Finland. The use of DAPs was estimated using definitions from the previous scientific literature. The Charlson Comorbidity Index (CCI) was used to estimate the burden of co-morbidity and the Mini-Mental State Examination test was used to assess cognitive function. The risks in the two study groups for hospital visits, number of days spent in hospital care and mortality were measured from 2000 to the end of 2003.

RESULTS

The unadjusted follow-up mortality was 20.7% and 9.5% among the users and non-users of DAPs, respectively (p = 0.010). However, the use of DAPs was not a significant predictor of mortality in multivariate analysis after adjustment for age, sex and CCI score (hazard ratio 1.57; 95% CI 0.78, 3.15). The mean ± SD number of hospital days per person-year was higher in the DAP user group (14.9 ± 32.5) than in the non-user group (5.2 ± 12.3) [p < 0.001]. In a bootstrap-type analysis of covariance adjusted for age, sex and CCI score, the use of DAPs predicted the number of days spent in hospital (p = 0.011).

CONCLUSIONS

The use of DAPs in older patients with stable CVD was associated with an increased number of hospital days but not with mortality.

Multiple risk factor interventions for primary prevention of coronary heart disease

BACKGROUND

Multiple risk factor interventions using counselling and educational methods assumed to be efficacious and cost-effective in reducing coronary heart disease (CHD) mortality and morbidity and that they should be expanded. Trials examining risk factor changes have cast doubt on the effectiveness of these interventions.

OBJECTIVES

To assess the effects of multiple risk factor interventions for reducing total mortality, fatal and non-fatal events from CHD and cardiovascular risk factors among adults assumed to be without prior clinical evidence CHD..

SEARCH STRATEGY

We updated the original search BY SEARCHING CENTRAL (2006, Issue 2), MEDLINE (2000 to June 2006) and EMBASE (1998 to June 2006), and checking bibliographies.

SELECTION CRITERIA

Randomised controlled trials of more than six months duration using counselling or education to modify more than one cardiovascular risk factor in adults from general populations, occupational groups or specific risk factors (i.e. diabetes, hypertension, hyperlipidaemia, obesity).

DATA COLLECTION AND ANALYSIS

Two authors extracted data independently. We expressed categorical variables as odds ratios (OR) with 95% confidence intervals (CI). Where studies published subsequent follow-up data on mortality and event rates, we updated these data.

MAIN RESULTS

We found 55 trials (163,471 participants) with a median duration of 12 month follow up. Fourteen trials (139,256 participants) with reported clinical event endpoints, the pooled ORs for total and CHD mortality were 1.00 (95% CI 0.96 to 1.05) and 0.99 (95% CI 0.92 to 1.07), respectively. Total mortality and combined fatal and non-fatal cardiovascular events showed benefits from intervention when confined to trials involving people with hypertension (16 trials) and diabetes (5 trials): OR 0.78 (95% CI 0.68 to 0.89) and OR 0.71 (95% CI 0.61 to 0.83), respectively. Net changes (weighted mean differences) in systolic and diastolic blood pressure (53 trials) and blood cholesterol (50 trials) were -2.71 mmHg (95% CI -3.49 to -1.93), -2.13 mmHg (95% CI -2.67 to -1.58 ) and -0.24 mmol/l (95% CI -0.32 to -0.16), respectively. The OR for reduction in smoking prevalence (20 trials) was 0.87 (95% CI 0.75 to 1.00). Marked heterogeneity (I(2) > 85%) for all risk factor analyses was not explained by co-morbidities, allocation concealment, use of antihypertensive or cholesterol-lowering drugs, or by age of trial.

AUTHORS' CONCLUSIONS

Interventions using counselling and education aimed at behaviour change do not reduce total or CHD mortality or clinical events in general populations but may be effective in reducing mortality in high-risk hypertensive and diabetic populations. Risk factor declines were modest but owing to marked unexplained heterogeneity between trials, the pooled estimates are of dubious validity. Evidence suggests that health promotion interventions have limited use in general populations.

Interest in healthy lifestyle and adherence to medications: Impact on mortality among elderly cardiovascular patients in the DEBATE Study

OBJECTIVE

We examined how a patient-centered consultation can help the physician to evaluate older patients' adherence to medical care and a healthy lifestyle. We hypothesised that an accurate estimate of adherence should be shown in their prognosis.

METHODS

Cardiovascular patients (>74 years) in an intervention study (the DEBATE Study) were divided according to physician's clinical impression: (1) "Active adherents" (N=53): those having a healthy lifestyle and adherent to medications. (2) "Passive adherents" (N=65): those not showing any particular interest in a healthy lifestyle but adherent to medications. (3) "Interested scepticals" (N=66): those showing an interest in a healthy lifestyle but feeling sceptical about medications. (4) "Passive non-adherents" (N=15): those having a sedentary lifestyle and non-adherence to medical treatments. The combined endpoint was permanent institutionalisation or death during the average 4.5-year follow-up.

RESULTS

Mortality during the 4.5-year follow-up ranged among groups 1-4: 15, 19, 26, and 53% (p=0.01), and the proportions permanently institutionalised 0, 2, 6, and 20% (p=0.003). Multivariate analyses with age, gender, Charlson comorbidity index, dependence in ADL activities and with group 1 as the reference (1.0) showed that both group 3 (HR 2.73, 95% CI 1.11-6.52) and group 4 (HR 6.24, 95% CI 1.88-20.67) were at significantly increased risk for institutionalisation or death.

CONCLUSION

In a patient-centered consultation adherence can be accurately evaluated, and such an evaluation is of significant value in the prognosis of older cardiovascular patients.

PRACTICE IMPLICATIONS

A patient's expression of attitudes towards medications and healthy lifestyle may be elicited in a patient-centered consultation. This patient-centered approach may help in modifying care to support appropriate, tailored treatments for individual patients.

Dementia associates with undermedication of cardiovascular diseases in the elderly: a population-based study

OBJECTIVE

To compare medication use in patients suffering from cardiovascular disease with and without dementia.

SUBJECTS

All inhabitants aged 75 and older in Lieto, Finland (n = 462, participation rate 82%).

MEASUREMENTS

Direct standardised assessments of dementia and cardiovascular diseases. Quantification of drug use by self-report and by prescription and drug container checks.

RESULTS

In multivariate analyses, the odds ratio for demented cardiovascular patients receiving any cardiovascular medication (use vs. non-use) was 0.31 (95% confidence interval 0.12-0.82). Compared to the non-demented, demented stroke patients were treated less often with antithrombotic agents (p = 0.041) and demented hypertensive patients less often with beta-blockers (p = 0.045).

CONCLUSION

Demented cardiovascular patients, even mildly to moderately demented, were prescribed fewer evidence-based cardiovascular medications than non-demented patients.

Multifactorial intervention to prevent recurrent cardiovascular events in patients 75 years or older: the Drugs and Evidence-Based Medicine in the Elderly (DEBATE) study: a randomized, controlled trial

OBJECTIVE

We aimed to examine whether better use of preventive methods and treatments of cardiovascular disease would reduce recurrent events in home-dwelling patients 75 years or older.

METHODS

This was a randomized, controlled trial (a practical clinical trial, the DEBATE), conducted in 2000 to 2003 in Helsinki, Finland. We recruited 400 vascular patients with mean age of 80 years from the community, and they were randomly assigned to the intervention group (n = 199) where both nonpharmacological and pharmacological cardiovascular treatments were optimized by a geriatrician according to current guidelines. The control group (n = 201) received the usual care. Main outcome measures were major cardiovascular disease events and total mortality and changes in risk factors and medications.

RESULTS

The groups were balanced at baseline. Mean duration of follow-up was 3.4 years. At 3 years, drug treatments had become more evidence-based in the intervention group. Consequently, total and low-density lipoprotein cholesterol levels (P < .0001) and systolic (P = .005) and diastolic (P = .009) blood pressure were significantly improved in the intervention group. However, neither primary end points (52 and 53 events in the intervention and control groups, respectively) nor total mortality (36 and 35 deaths) were significantly different between the two groups. No special adverse effects were encountered.

CONCLUSION

It was possible and safe to institute evidence-based cardiovascular treatments and improve risk factors in patients 75 years or older in a pragmatic setting. During 3.4 years, however, this was not converted to clinical benefits.

Cholesterol and Glucose Metabolism and Recurrent Cardiovascular Events Among the Elderly

OBJECTIVES

The aim of this research was to evaluate the prognostic value of cholesterol absorption assessed with the serum cholestanol-to-cholesterol concentration ratio (lower level reflects decreased cholesterol absorption) among elderly cardiovascular patients (DEBATE [Drugs and Evidence-Based Medicine in the Elderly] study).

BACKGROUND

The components of the metabolic syndrome have been unexpectedly associated with better prognosis among elderly cardiovascular patients. On the other hand, a metabolic syndrome-type state is characterized by high synthesis and decreased absorption of cholesterol.

METHODS

This was a prospective cohort study of home-dwelling individuals age 75 years and older with cardiovascular diseases (247 women, 129 men) recruited from the community. Main outcome measure was multivariate-adjusted time to 3.4-year mortality and recurrent major cardiovascular events.

RESULTS

Serum total and low-density lipoprotein cholesterol levels did not predict outcome. Instead, the mortality risk (64 deaths) increased with increasing levels of cholestanol-to-cholesterol ratio. Patients in the 2nd, 3rd, and 4th quartiles had a relative hazard ratio (HR) for death of 2.54 (95% confidence interval [CI] 1.05 to 6.12), 2.48 (95% CI 1.03 to 6.00), and 3.53 (95% CI 1.52 to 8.19) compared with the lowest quartile, even though 50% of individuals in the lowest cholestanol quartile had metabolic syndrome or diabetes. In multivariate models, the lowest cholestanol ratio quartile was independently associated with lower mortality (relative HR, 0.37, 95% CI 0.17 to 0.81), and with fewer major cardiovascular events (115 events, relative HR, 0.59, 95% CI 0.35 to 0.98).

CONCLUSIONS

Low cholesterol absorption was associated with fewer recurrent cardiovascular events, and with better survival in elderly patients despite frequent abnormalities of glucose metabolism.

Interaction of herpesviridae, APOE gene, and education in cognitive impairment

While high age, low level of education and APOE epsilon4 allele are known to predict dementia, there is recent data suggesting that certain viruses and subtypes of APOE epsilon3 could be involved, too. We investigated these relationships in a home-dwelling cohort of 357 elderly people with various cardiovascular diseases (DEBATE study). MMSE score below 24 was used to define cognitive impairment (n = 58). When adjusted for age and the presence of diabetes, multivariate analysis demonstrated maximally increased risk of cognitive impairment in association with a combination of three factors: seropositivity for herpesviridae, presence of APOE epsilon4, and low education (risk ratio 6.1, 95% CI 2.4-15.2). In the subcohort of APOE3/3 individuals (n = 216) homozygosity for the -219G epsilon3 haplotype showed a similar association (risk ratio 8.8, 95% CI 2.6-29.8). These results demonstrate an interaction of specific genetic (APOE) and environmental (education and herpesviridae) risk factors in the development of cognitive impairment and indicate that not only the epsilon4 allele of APOE but also the epsilon3 haplotype is a risk factor for dementia.

Older people's reasoning for resuscitation preferences and their role in the decision-making process

OBJECTIVES

To investigate older patients' reasoning for their cardiopulmonary resuscitation (CPR) preferences and the related decision-making process (DMP).

METHODS AND SUBJECTS

In a descriptive study 220 elderly home-dwelling cardiovascular patients were interviewed and asked to justify their CPR preferences according to the given statements. Questions related to DMP were asked and their physical function, cognition, mood, and quality of life were assessed.

RESULTS

Resuscitation preferences were associated with several patient characteristics, such as age, mood and quality of life. Patients preferring CPR (114/220, 52%) estimated their prognosis of CPR to be better than those preferring to forgo CPR. They justified their view: "Life is precious and worth living for me" (92%), "Maintaining life is a value of its own" (92%), "I feel needed by my family and my closest" (81%). Participants preferring to forgo CPR (106/220, 48%) justified: "I have already gained old age and led a full life" (88%), "People cannot decide these things" (72%). Only 9% of patients had discussed, and 38% would like to discuss preferences for life-sustaining treatments (LSTs) with their physician. However, 80% of respondents felt that the patients should take some part in the DMP; either alone (9%), together with a physician (23%), or together with a physician and a close relative (48%).

CONCLUSIONS

Older people justify their resuscitation preferences highlighting their experiences of meaningful life or fulfillment of their life, interpersonal relationships with their loved ones and presumed outcome of CPR. Less than a half of the patients wished to discuss CPR and LSTs preferences in their current situation with their physician, but nevertheless wanted to participate in the DMP of end-of-life treatment. Physicians should assess patients' own preferences in-depth.

CYP3A5 Genotype is Associated with Diagnosis of Hypertension in Elderly Patients

OBJECTIVE

The aim of this study was to address the presently controversial question of whether cytochrome P450 (CYP) 3A5 polymorphism is associated with hypertension.

METHOD

We studied 373 elderly (age > or =75 years) Finnish (Caucasian) patients from the ongoing DEBATE (Drugs and Evidence Based Medicine in the Elderly) trial. The patients were classified into those with a history of hypertension (n = 229) and those without a history of hypertension (n = 144) on the basis of a detailed questionnaire on each patient's medical history and an interview. The patients were genotyped for the CYP3A5 6986A/G single nucleotide polymorphism (SNP) [CYP3A5*1/*3 alleles].

RESULTS

The proportion of individuals with the CYP3A5*1/*3 genotype, i.e. CYP3A5 expressors, was significantly higher among patients with a diagnosis of hypertension than among patients without (18.3% vs 9.0%, p = 0.016). The corresponding odds ratio was 2.26 (95% CI 1.17, 4.38). The allele and genotype frequencies for the two control SNPs, ABCB1 (MDR1) 3435C/T and SLCO1B1 521T/C, did not differ between the two groups.

CONCLUSION

This work lends support to the theory that the polymorphic CYP3A5 enzyme may be involved in regulation of blood pressure. The possible role of CYP3A5 as a genetic contributor to hypertension susceptibility warrants further study.

Living Will, Resuscitation Preferences, and Attitudes towards Life in an Aged Population

BACKGROUND

The growth of life-sustaining medical technology and greater attention to medical care at the end of life have provoked interest in issues related to advance care planning.

OBJECTIVE

To investigate how having a living will (LW), resuscitation preferences, health condition, and life attitudes are related in home-dwelling elderly people.

METHODS

In a cross-sectional descriptive study, detailed assessments were made of 378 home-dwelling elderly individuals participating in a cardiovascular prevention study (DEBATE Study). The participants were inquired about a preexistence of a written document (LW) concerning life-sustaining care, preferences of cardiopulmonary resuscitation (CPR) in their current situation, and attitudes towards life. General health, physical and cognitive functioning, the presence of depression, and quality of life were also assessed.

RESULTS

Forty-four of the 378 participants (12%) had a LW. As compared with those without one (n = 334), there were more women [82% (36/44) vs. 63% (210/334)] and widows [57% (25/44) vs. 41% (135/334)] among those with a LW. They were also more educated and considered their health to be better. Despite having a LW, 46% (20/44) of them preferred CPR in their current condition, a proportion not statistically different from the 58% (194/334) of the individuals without a LW. In the whole sample, 39% (149/378) of the individuals preferred to forgo CPR. As compared with those preferring CPR, they were older, more often women, and widowed. Participants preferring to forgo CPR had a poorer quality of life, were more lonely, and showed signs of depression more often than those preferring CPR. The preference to forgo CPR was related to attitudes towards life regardless of physical or cognitive functioning.

CONCLUSIONS

Having a LW does not reduce the reported preference of CPR which is related more to current mental status and life attitudes. In-depth assessment of the patient's preferences should be performed in any comprehensive care plan.

Benefits of optimising drug treatment in home-dwelling elderly patients with coronary artery disease

Coronary artery disease (CAD) is prevalent in the elderly and often leads to disability. Consequently, strategies for optimising the prevention and treatment of CAD in the elderly are important from both the individual and societal perspectives. Although it is common knowledge that the elderly are heavy consumers of drugs, there is evidence to show that there is under-prescribing of evidence-based medical therapies in the home-dwelling elderly coronary patient and there may be overuse of some non-evidence-based (antioxidants) and purely symptomatic treatments. In particular, aspirin (acetylsalicylic acid), beta-adrenoceptor antagonists, ACE inhibitors and HMG-CoA reductase inhibitors are under-utilised. Although the evidence base is largely drawn from trials including patients younger than 75 years, it is reasonable to assume that the data applies to patients aged over 75 years and that better use of evidence-based medicines would provide benefits to the home-dwelling aged patient. Evidence from the few multifactorial studies available suggest possible benefits including reduction of cardiovascular events, less disability and better quality of life in old age. At the societal level, this would be reflected in fewer hospitalisations and institutionalisations, which means decreased cost of elderly care.

Secondary prevention of coronary heart disease in the elderly

OBJECTIVE

To review relevant literature supporting the use of aspirin, beta-blockers, lipid-lowering agents, and angiotensin-converting enzyme (ACE) inhibitors for the secondary prevention of coronary heart disease (CHD) in an elderly patient population aged >/=65 years.

DATA SOURCES

A MEDLINE search (1990-May 2003) was conducted using the key terms coronary heart disease, secondary prevention and elderly.

STUDY SELECTION AND DATA EXTRACTION

Primary and tertiary literature relating to the use of aspirin, beta-blockers, lipid-lowering agents, and ACE inhibitors in the elderly were reviewed.

DATA SYNTHESIS

CHD is the leading cause of morbidity and mortality in persons >/=65 years of age, and the use of pharmacologic agents has created a considerable opportunity for reducing recurrent events in those with established disease. This, combined with the aging of the US population, is creating an increase in the number of older adults eligible for secondary prevention. In 2002, the American Heart Association issued a scientific statement on the benefits of specific secondary prevention risk factor interventions in older adults. This article reviews pertinent findings from this statement, along with additional data supporting the use of pharmacologic agents for the secondary prevention of CHD in the elderly.

CONCLUSIONS

Data suggest that use of aspirin, beta-blockers, lipid-lowering agents, and ACE inhibitors are effective in secondary prevention of CHD in individuals aged >/=65 years. This benefit is similar to, and often greater than, that observed in younger patients. We believe that these agents should be prescribed for all elderly patients without contraindications. Ongoing studies and future clinical trials will more clearly elucidate the benefits of secondary prevention of CHD, particularly in persons >/=75 years of age, to determine the magnitude of benefits that can be achieved in this population.

Selective impairment of frontal-executive cognitive function in african americans with cardiovascular risk factors

OBJECTIVES

To determine whether a summary cardiovascular risk score is associated with an increased risk of frontal-executive cognitive impairment.

DESIGN

Cross-sectional study.

SETTING

Subjects were recruited from senior centers, senior housing complexes, and communities in the Boston metropolitan area.

PARTICIPANTS

Forty-three predominantly female elderly African Americans.

MEASUREMENTS

Cardiovascular risk factors were assessed during an interview and clinical examination. For each subject, the total number of cardiovascular (CV) risk factors was summed to compute a CV risk score. A battery of neuropsychological tests was administered that examined memory, visuospatial abilities, and frontal-executive functions. Cognitive test scores were transformed into domain-specific (memory, visuospatial, frontal-executive) composite z scores. Cognitive impairment for each composite z score was defined as performance less than the median for the study group. Multivariate logistic regression was used to examine the relationship between the CV risk score and the risk for cognitive impairment in the three cognitive domains of interest.

RESULTS

After controlling for age and education, the CV risk score was associated only with frontal-executive cognitive impairment (odds ratio (OR)=2.44, 95% confidence interval (CI)=1.06-5.65). The CV risk score was not associated with the risk of memory (OR=1.30, 95% CI=0.64-2.67) or visuospatial impairment (OR=1.49, 95% CI=0.66-3.36). Greater CV risk scores were associated with an increased likelihood of having frontal-executive cognitive impairment.

CONCLUSION

CV risk factors may exert a specific deleterious effect on frontal-executive cognitive abilities as opposed to memory or visuospatial functions. Associated executive dysfunction may compromise the ability of patients with CV risk factors to comply with recommendations for risk reduction.

Impact of viral and bacterial burden on cognitive impairment in elderly persons with cardiovascular diseases

BACKGROUND AND PURPOSE

Inflammation and infectious etiology have been implicated in the pathogenesis of dementia. We sought to investigate whether the seropositivity of common infections was associated with cognitive function.

METHODS

Viral burden (seropositivity for herpes simplex virus type 1 [HSV-1], herpes simplex virus type 2 [HSV-2], or cytomegalovirus [CMV]) and bacterial burden (Chlamydia pneumoniae and Mycoplasma pneumoniae) were related to cognitive status and its impairment among 383 home-dwelling elderly with cardiovascular diseases (mean age, 80 years). The Mini-Mental State Examination (MMSE) and its changes and the Clinical Dementia Rating (CDR) were used to define cognitive impairment.

RESULTS

At baseline, 0 to 1, 2, and 3 positive titers toward viruses were found in 48 (12.5%), 229 (59.8%), and 106 individuals (27.7%), respectively. MMSE points decreased with increasing viral burden (P=0.03). At baseline, 58 individuals (15.1%) had cognitive impairment, which after adjustments was significantly associated with seropositivity for 3 viruses (hazard ratio, 2.5; 95% CI, 1.3 to 4.7). MMSE score decreased in 150 (43% of 348) during 12-month follow-up. After adjustment for MMSE score at baseline and with 0 to 1 seropositivities as reference (1.0), the hazard ratios were 1.8 (95% CI, 0.9 to 3.6) and 2.3 (95% CI, 1.1 to 5.0) for 2 and 3 seropositivities, respectively. The prevalence of possible or definite dementia according to CDR also increased with viral burden. No significant associations were observed between bacterial burden and cognition.

CONCLUSIONS

Viral pathogen burden of HSV and CMV was associated with cognitive impairment in home-dwelling elderly persons with cardiovascular diseases. The results need to be tested in larger databases, but they may offer a preventable cause of cognitive decline.