Exclusion of Elderly People from Randomized Clinical Trials of Drugs for Ischemic Heart Disease

Exclusion of older patients from randomized clinical trials in Parkinson's disease

Prevalence of Parkinson's disease (PD) increases with age. The purpose of this study was to evaluate the eligibility criteria in randomized clinical trials (RCTs) in PD, especially those limiting the enrollment of older adults. We examined RCTs of pharmacological and non-pharmacological anti-parkinsonian interventions registered with ClinicalTrials.gov and started from 2013 through 2022. Primary outcome was proportion of RCTs with an upper age limit of 85 years of age or less. Secondary outcome was proportion of RCTs with other exclusion criteria. Associations between trial characteristics and the presence of the age limits were determined using logistic regression. Our study included 420 RCTs. Two hundred thirty-nine (57%) of these had an upper age limit of 85 years of age or less. Proportion of these trials significantly increased over time. The odds of the presence of an upper age limit were significantly associated with the investigational site location, phase, and timeframe for the primary endpoint assessment. Three hundred fifty-six (85%) trials had other eligibility criteria limiting the enrollment of older patients; these often (n = 285; 68%) included cognitive impairment. Overall, 386 (92%) RCTs either explicitly excluded older adults or had criteria indirectly limiting their enrollment. Underrepresentation of older patients in clinical trials in PD considerably reduces the generalizability of their results. Some eligibility criteria should be modified to enable the investigators to assess the benefits and harms of new therapeutic interventions in older adults. This problem is important in view of rapidly growing number of older patients with PD.

The global burden of ischemic heart disease attributed to high fasting plasma glucose: Data from 1990 to 2019

Background

Ischemic heart disease (IHD) is the leading cause of death worldwide. High fasting plasma glucose (FPG) is an increasing risk factor for IHD. We aimed to explore the long-term trends of high FPG-attributed IHD mortality during 1990-2019.

Methods

Data were obtained from the Global Burden of Disease Study 2019 database. Deaths, disability-adjusted life-years (DALYs), the age-standardized mortality rate (ASMR) and age-standardized DALY rate (ASDR) of IHD attributable to high FPG were estimated by sex, socio-demographic index (SDI), regions and age. Estimated annual percentage changes (EAPCs) were calculated to assess the trends of ASMR and ASDR of IHD attributable to high FPG.

Results

IHD attributable to high FPG deaths increased from 1.04 million (0.62-1.63) in 1990 to 2.35 million (1.4-3.7) in 2019, and the corresponding DALYs rose from 19.82 million (12.68-29.4) to 43.3 million (27.8-64.2). In 2019, ASMR and ASDR of IHD burden attributable to high FPG were 30.45 (17.09-49.03) and 534.8 (340.7-792.2), respectively. The highest ASMR and ASDR of IHD attributable to high FPG occurred in low-middle SDI quintiles, with 39.28 (22.40-62.76) and 742.3 (461.5-1117.5), respectively, followed by low SDI quintiles and middle SDI quintiles. Males had higher ASMR and ASDR compared to females across the past 30 years. In addition, ASRs of DALYs and deaths were highest in those over 95 years old.

Conclusion

High FPG-attributed IHD mortality and DALYs have increased dramatically and globally, particularly in low, low-middle SDI quintiles and among the elderly. High FPG remains a great concern on the global burden of IHD and effective prevention and interventions are urgently needed to curb the ranking IHD burden, especially in lower SDI regions.

Exclusion of older adults from randomized controlled trials in rheumatoid arthritis

OBJECTIVES

To assess eligibility criteria that either explicitly or implicitly exclude older patients from randomized controlled trials (RCTs) in RA.

METHODS

Our analysis included RCTs of pharmacological interventions registered with ClinicalTrials.gov and started between 2013 and 2022. Co-primary outcomes were proportions of trials with an upper age limit and the eligibility criteria indirectly increasing risk of the exclusion of older adults.

RESULTS

A total of 143/290 (49%) trials had an upper age limit of 85 years or less. Multivariable analysis showed that the odds of an upper age limit were significantly lower in trials performed in the USA [adjusted odds ratio (aOR), 0.34; CI, 0.12-0.99; P = 0.04] and intercontinental trials (aOR, 0.4; CI, 0.18-0.87; P = 0.02). In total, 154/290 (53%) trials had at least one eligibility criterion implicitly excluding older adults. These included specific comorbidities (n = 114; 39%), compliance concerns (n = 67; 23%), and broad and vague exclusion criteria (n = 57; 20%); however, we found no significant associations between these criteria and trial characteristics. Overall, 217 (75%) trials either explicitly or implicitly excluded older patients; we also noted a trend towards increasing proportion of these trials over time. Only one trial (0.3%) enrolled solely patients aged 65 and older.

CONCLUSION

Older adults are commonly excluded from RCTs in RA based on both age limits and other eligibility criteria. This seriously limits the evidence base for the treatment of older patients in clinical practice. Given the growing prevalence of RA in older adults, relevant RCTs should be more inclusive to them.

The current status of clinical trials on cancer and age disparities among the most common cancer trial participants

OBJECTIVE

To illustrate the status of all cancer clinical trials and characterize clinical trial enrollment disparities in the most common cancer.

METHODS

Clinical trial data were extracted from ClinicalTrials.gov website. All searched clinical trials were included in the current status analysis of clinical trials on cancer. Among all the clinical trials, only trials addressing single disease sites of breast, prostate, colorectal, or lung (BPCRL) cancer were included in the age disparities analysis. The difference in median age (DMA) between the trial participant median age and the population-based disease-site-specific median age was calculated for each trial.

RESULTS

A total of 7747 clinical trials were included in the current status analysis of clinical trials on cancer. The number of registered trials had been increasing from 2008 to 2021 (AAPC = 50.60, 95% CI 36.60, 66.00, P < 0.05). Of the 7747 trials, 1.50% (116) of the studies were clinical trials for the elderly aged 60 years or older. 322 trials were included in the age disparities analysis. For all trials, the median DMA was - 8.15 years (P25, P75, - 10.83 to - 2.98 years, P < 0.001). The median DMA were - 9.55 years (P25, P75, - 11.63 to - 7.11 years), - 7.10 years (P25, P75, - 9.80 to - 5.70 years), - 9.75 years (P25, P75, - 11.93 to - 7.35 years), 3.50 years (P25, P75, 0.60 to 4.55 years), respectively, for breast cancer, colorectal cancer, lung cancer and prostate cancer.

CONCLUSION

The numbers of registered clinical trials show an upward trend. Age disparities between trial participants and diagnosed disease population are present in BPCRL cancer trials and appear to be increasing over time. Equitable participation in clinical trials on the basis of age is crucial for advancing medical knowledge and evaluating the safety and efficacy of new treatments that are generalizable to aging populations.

Optimal anti-platelet therapy for older patients with acute coronary syndrome: a network meta-analysis of randomized trials comprising 59,284 older patients

The aim of this study was to identify the optimal anti-platelet therapy in older acute coronary syndrome (ACS) patients with a mean age ≥ 60 years by comparing the efficacy and safety of different anti-platelet therapies. The selection of antiplatelet therapy in older patients with ACS is a clinical challenge. Numerous evidences indicate that the de-escalation of dual anti-platelet therapy (DAPT) or P2Y12 inhibitor monotherapy may reduce bleeding risk without increasing thrombotic events. However, there is a lack of systematic reviews and optimal strategy analysis regarding older ACS patients. Randomized controlled trials (RCTs) of anti-platelet therapy in older ACS patients were identified. Major adverse cardiovascular events (MACE) were the primary outcome. Secondary outcomes included all death, cardiovascular death, myocardial infarction, stroke, stent thrombosis, and trial-defined major bleeding. Frequentist and Bayesian network meta-analyses were conducted. Treatments were ranked on posterior probability. Summary odds ratios (ORs) were estimated using Bayesian network meta-analysis. A total of 12 RCTs including 59,284 older ACS patients treated with five anti-platelet strategies were included. Ticagrelor monotherapy after 3 months DAPT was comparable to the other strategies (OR 0.73; 95% CI 0.32-1.6) in terms of MACE risk. Additionally, P score analysis and SUCRA Bayesian analysis showed that it was the most beneficial treatment for all deaths, cardiovascular death and revascularization. For safety, although there was no significant difference in direct comparisons, both SUCRA Bayesian (0.806) and P score (0.519) analysis suggested that ticagrelor monotherapy was the safest strategy. The current evidence demonstrated that ticagrelor monotherapy after 3 months DAPT may be a promising approach for achieving a more favorable balance between risk and benefit for older ACS patients, with a relatively low bleeding risk and without an increased risk of MACE events. Moreover, it remains the preferred option for clinical outcomes such as all death, CV death and revascularization. Further high-quality and long-term studies are required to validate anti-platelet therapies among older ACS patients.

Guideline concordant prescribing following myocardial infarction in people who are frail: A systematic review

AIMS

The risk-to-benefit ratio of cardioprotective medications in frail older adults is uncertain. The objective was to systematically review prescribing of guideline-recommended cardioprotective medications following myocardial infarction (MI) in people who are frail.

DATA SOURCES

Ovid Medline, PubMed and Cochrane were searched from inception to October 2022 for studies that reported prescribing of one or more cardioprotective medication classes post-MI or acute coronary syndromes in people with frailty.

STUDY SELECTION

We included observational studies that reported prescribing of cardioprotective medications post-MI stratified by frailty status.

RESULTS

Overall, 16 cohort studies published from 2013 to 2022 that used seven different frailty scales were included. Prescribing of all cardioprotective medication classes following MI was lower in frail compared to non-frail people, with absolute rates of prescribing varying substantially across studies. Median prescribing in frail and non-frail people, respectively, was 88.9% (IQR 81.5-96.2) and 93.1% (IQR 92.0-98.9) for aspirin; 68.1% (IQR 61.9-91.2) and 86.7% (IQR 79.5-92.8) for P2Y12-inhibitors; 83.1% (IQR 76.9-91.3) and 94.0% (IQR 87.1-95.9) for lipid-lowering therapy; 67.9% (IQR 60.6-74.0) and 74.7% (IQR 71.3-84.5) for angiotensin-converting enzyme inhibitor/angiotensin II receptor blockers; and 74.1% (IQR 69.2-79) and 77.6% (IQR 71.8-85.9) for beta-blockers.

CONCLUSION

People who were frail were less likely to be prescribed guideline recommended medication classes post-MI than those who were non-frail. Further research is needed into treatment benefits and risks in frail people to avoid unnecessarily withholding treatment in this high-risk population, while also minimising potential for medication related harm.

Good clinical research practice (GCRP) in pharmacodynamic studies of neuromuscular blocking agents III: The 2023 Geneva revision

The set of guidelines for good clinical research practice in pharmacodynamic studies of neuromuscular blocking agents was developed following an international consensus conference in Copenhagen in 1996 (Viby-Mogensen et al., Acta Anaesthesiol Scand 1996, 40, 59-74); the guidelines were later revised and updated following the second consensus conference in Stockholm in 2005 (Fuchs-Buder et al., Acta Anaesthesiol Scand 2007, 51, 789-808). In view of new devices and further development of monitoring technologies that emerged since then, (e.g., electromyography, three-dimensional acceleromyography, kinemyography) as well as novel compounds (e.g., sugammadex) a review and update of these recommendations became necessary. The intent of these revised guidelines is to continue to help clinical researchers to conduct high-quality work and advance the field by enhancing the standards, consistency, and comparability of clinical studies. There is growing awareness of the importance of consensus-based reporting standards in clinical trials and observational studies. Such global initiatives are necessary in order to minimize heterogeneous and inadequate data reporting and to improve clarity and comparability between different studies and study cohorts. Variations in definitions of endpoints or outcome variables can introduce confusion and difficulties in interpretation of data, but more importantly, it may preclude building of an adequate body of evidence to achieve reliable conclusions and recommendations. Clinical research in neuromuscular pharmacology and physiology is no exception.

Impact of Advanced Age on the Incidence of Major Adverse Cardiovascular Events in Patients with Type 2 Diabetes Mellitus and Stable Coronary Artery Disease in a Real-World Setting in Spain

Patients with type 2 diabetes mellitus (T2DM) and coronary artery disease (CAD) without myocardial infarction (MI) or stroke are at high risk for major cardiovascular events (MACEs). We aimed to provide real-world data on age-related clinical characteristics, treatment management, and incidence of major cardiovascular outcomes in T2DM-CAD patients in Spain from 2014 to 2018. We used EHRead® technology, which is based on natural language processing and machine learning, to extract unstructured clinical information from electronic health records (EHRs) from 12 hospitals. Of the 4072 included patients, 30.9% were younger than 65 years (66.3% male), 34.2% were aged 65-75 years (66.4% male), and 34.8% were older than 75 years (54.3% male). These older patients were more likely to have hypertension (OR 2.85), angina (OR 1.64), heart valve disease (OR 2.13), or peripheral vascular disease (OR 2.38) than those aged <65 years (p < 0.001 for all comparisons). In general, they were also more likely to receive pharmacological and interventional treatments. Moreover, these patients had a significantly higher risk of MACEs (HR 1.29; p = 0.003) and ischemic stroke (HR 2.39; p < 0.001). In summary, patients with T2DM-CAD in routine clinical practice tend to be older, have more comorbidities, are more heavily treated, and have a higher risk of developing MACE than is commonly assumed from clinical trial data.

Research Inclusion Across the Lifespan: A Good Start, but There Is More Work to Be Done

While older adults account for a disproportionate amount of healthcare spending, they are often underrepresented in clinical research needed to guide clinical care. The purpose of this perspective is to make readers aware of new data on age at enrollment for participants included in National Institutes of Health (NIH)-funded clinical research. We highlight key findings of relevance to general internal medicine and suggest ways readers could support the inclusion of older adults in clinical research. Data from the NIH Research Inclusion Statistics Report show that there were 881,385 participants enrolled in all NIH-funded clinical research in 2021, of whom 170,110 (19%) were 65 years and older. However, on average, studies included a far lower percentage of older adults. Additionally, there were many conditions for which overall enrollment rates for older adults were lower than would be expected. For example, while 10% of participants in studies related to diabetes were ≥ 65 years old, older individuals represent 43% of all prevalent diabetes in the USA. Researchers should work with clinicians to advocate for older adults and ensure their participation in clinical research. Best practices and resources for overcoming common barriers to the inclusion of older adults in research could also be disseminated.

Matching enrolled trial participants to disease demographics: Using IRB submissions to identify opportunities for researcher training

Background

Many diseases are highly prevalent in older adults, yet older adults are often underrepresented in corresponding trials. Our objectives were to (1) determine alignment between Institutional Review Board (IRB) protocol age ranges and enrollment demographics to disease demographics pre- and post-implementation of the 2019 National Institutes of Health (NIH) Lifespan Policy and (2) raise awareness about inclusive recruitment to principal investigators (PIs).

Methods

This was a pre-post study. We reviewed investigator-initiated studies meeting eligibility criteria at Oregon Health & Science University from 2017 to 2018 to determine baseline alignment. Alignment was defined by the level of matching between protocol/enrollment age and disease demographics: 2 points for full match, 1 point for partial match, and 0 points for mismatch. After the NIH policy implementation, we reviewed new studies for alignment. When a mismatch was determined, we contacted PIs (either at initial IRB protocol submission or during ongoing recruitment) to raise awareness and provide strategies to expand inclusion of older adults in their trials.

Results

Studies that matched IRB protocol ages to disease demographics significantly improved from 78% pre-implementation to 91.2% post-implementation. Similarly, study enrollment ages matching disease demographics increased by 13.4% following the implementation (74.5%-87.9%). Out of 18 post-implementation mismatched studies, 7 PIs accepted a meeting and 3 subsequently changed their protocol age ranges.

Conclusion

This study highlights strategies that translational institutes and academic institutions could use to identify research studies whose participants do not align with disease demographics, offering opportunities for researcher awareness and training to enhance inclusion.

An analysis of DPV and DIVE registry patients with chronic kidney disease according to the finerenone phase III clinical trial selection criteria

BACKGROUND

The FIDELIO-DKD and FIGARO-DKD randomized clinical trials (RCTs) showed finerenone, a novel non-steroidal mineralocorticoid receptor antagonist (MRA), reduced the risk of renal and cardiovascular events in patients with type 2 diabetes mellitus (T2DM) and chronic kidney disease (CKD). Using RCT inclusion and exclusion criteria, we analyzed the RCT coverage for patients with T2DM and CKD in routine clinical practice in Germany.

METHODS

German patients from the DPV/DIVE registries who were ≥ 18 years, had T2DM and CKD (an estimated glomerular filtration rate [eGFR] < 60 mL/min/1.73 m² OR eGFR ≥ 60 mL/min/1.73m² and albuminuria [≥ 30 mg/g]) were included. RCT inclusion and exclusion criteria were then applied, and the characteristics of the two populations compared.

RESULTS

Overall, 65,168 patients with T2DM and CKD were identified from DPV/DIVE. Key findings were (1) Registry patients with CKD were older, less often male, and had a lower eGFR, but more were normoalbuminuric vs the RCTs. Cardiovascular disease burden was higher in the RCTs; diabetic neuropathy, lipid metabolism disorders, and peripheral arterial disease were more frequent in the registry. CKD-specific drugs (e.g., angiotensin-converting enzyme inhibitors [ACEi] and angiotensin receptor blocker [ARBs]) were used less often in clinical practice; (2) Due to the RCT's albuminuric G1/2 to G4 CKD focus, they did not cover 28,147 (43.2%) normoalbuminuric registry patients, 4,519 (6.9%) albuminuric patients with eGFR < 25, and 6,565 (10.1%) patients with microalbuminuria but normal GFR (≥ 90 ml/min); 3) As RCTs required baseline ACEi or ARB treatment, the number of comparable registry patients was reduced to 28,359. Of these, only 12,322 (43.5%) registry patients fulfilled all trial inclusion and exclusion criteria. Registry patients that would have been eligible for the RCTs were more often male, had higher eGFR values, higher rates of albuminuria, more received metformin, and more SGLT-2 inhibitors than patients that would not be eligible.

CONCLUSIONS

Certain patient subgroups, especially non-albuminuric CKD-patients, were not included in the RCTs. Although recommended by guidelines, there was an undertreatment of CKD-patients with renin-angiotensin system (RAS) blockers. Further research into patients with normoalbuminuric CKD and a wider prescription of RAS blocking agents for CKD patients in clinical practice appears warranted.

Age-based exclusion is common and multifactorial in spinal RCTs: a systematic review and quantitative analysis

Most diseases of the spine disproportionately impact older persons, with the modal (i.e., commonest) patient a female in their 8th decade of life. We examined the corpus of spinal RCTs to determine how many included "average" spine patients. We searched PubMed for randomized clinical trials published in the top 7 spine journals over a period of 5 years from 2016 to 2020 and extracted nominal upper age cut-offs and the distribution of ages actually recruited. We identified 186 trials of 26,238 patients. We found that only 4.8% of trials could be applied to an "average" 75-year-old patient. This age-based exclusion was not dependent on funding source. Age-based exclusion was exacerbated by explicit upper age cut-offs, however, the age-based exclusion went beyond explicit age cut-offs. Only few trials were applicable to older patients even amongst trials with no age cut-off specified. Age-based exclusion from clinical trials starts at late middle age. The mismatch between spinal patient's age seen in clinical practice and spinal patient's age in trials was so severe that over the 5 years (2016-2020) almost no RCT evidence was produced applicable to the "average" aged-patient across the body of literature available. In conclusion, age-based exclusion is ubiquitous, multifactorial, and happens on a supratrial level. Eliminating age-based exclusion involves more than an arbitrary lifting of explicitly stated upper age cut-offs. Instead, recommendations include increasing input from geriatricians and ethics committees, establishing updated or new models of cares, and creating new protocols to facilitate further research.

Duloxetine, Gabapentin, and the Risk for Acute Myocardial Infarction, Stroke, and Out-of-Hospital Death in Medicare Beneficiaries With Non-Cancer Pain

OBJECTIVE

Duloxetine is a serotonin-norepinephrine reuptake inhibitor prescribed for musculoskeletal and other forms of chronic pain. Its dual pharmacologic properties have the potential to either raise or lower cardiovascular risk: adrenergic activity may increase the risk for acute myocardial infarction (AMI) and stroke, but antiplatelet activity may decrease risk. Gabapentin is another nonopioid medication used to treat pain, which is not thought to have adrenergic/antiplatelet effects. With the current emphasis on the use of nonopioid medications to treat patients with chronic pain, assessing cardiovascular risks associated with these medications among high-risk patients is important.

MATERIALS AND METHODS

We conducted a retrospective cohort study among a 20% sample of Medicare enrollees, aged 65 to 89, with chronic pain who were new users between 2015 and 2018 of either duloxetine (n = 34,009) or gabapentin (n = 233,060). We excluded individuals with cancer or other life-threatening conditions at study drug initiation. The primary outcome was a composite of AMI, stroke, and out-of-hospital mortality. We adjusted for comorbidity differences with time-dependent inverse probability of treatment weighting.

RESULTS

During 115,668 person-years of follow-up, 2361 patients had the composite primary outcome; the rate among new users of duloxetine was 16.7/1000 person-years compared with new users of gabapentin (21.1/1000 person-years), adjusted hazard ratio = 0.98 (95% CI: 0.83, 1.16). Results were similar for the individual components of the composite outcome as well as in analyses stratified by demographic and clinical characteristics.

DISCUSSION

In summary, cohort Medicare patients with non-cancer pain beginning treatment with duloxetine had rates of AMI, stroke, and out-of-hospital mortality comparable to those who initiated gabapentin.

Improving representativeness in trials: a call to action from the Global Cardiovascular Clinical Trialists Forum

Participants enrolled in cardiovascular disease (CVD) randomized controlled trials are not often representative of the population living with the disease. Older adults, children, women, Black, Indigenous and People of Color, and people living in low- and middle-income countries are typically under-enrolled in trials relative to disease distribution. Treatment effect estimates of CVD therapies have been largely derived from trial evidence generated in White men without complex comorbidities, limiting the generalizability of evidence. This review highlights barriers and facilitators of trial enrollment, temporal trends, and the rationale for representativeness. It proposes strategies to increase representativeness in CVD trials, including trial designs that minimize the research burden on participants, inclusive recruitment practices and eligibility criteria, diversification of clinical trial leadership, and research capacity-building in under-represented regions. Implementation of such strategies could generate better and more generalizable evidence to reduce knowledge gaps and position the cardiovascular trial enterprise as a vehicle to counter existing healthcare inequalities.

Eligibility criteria in NIH-funded clinical trials: Can adults with intellectual disability get in?

BACKGROUND

Although scientific breakthroughs can promote health equity, there is concern that adults with intellectual disability, a health disparities population, may be excluded from clinical trials.

OBJECTIVE

To determine the extent to which adults with intellectual disability are subject to exclusion from National Institutes of Health (NIH)-funded clinical trials.

METHODS

We studied recent NIH-funded Phase 2/3, 3, and 4 clinical trials of United States-based working-age adults (>18 < 55 years of age) listed in ClinicalTrials.gov. We coded eligibility criteria for inclusion, direct exclusion, and indirect exclusion of adults with intellectual disability.

RESULTS

We rarely identified studies that directly include adults with intellectual disability. Most studies (74.6%) had eligibility criteria that directly and/or indirectly exclude adults with intellectual disability. Approximately one-third of studies had direct exclusion criteria based on cognitive impairment or diagnosis of intellectual disability. Nearly 65% of studies indirectly excluded adults with intellectual disability based on factors likely associated with intellectual disability (e.g., functional capacity, inability to read/write, and/or research staff discretion).

CONCLUSIONS

We found less exclusion based on diagnosis of intellectual disability than anticipated. Nonetheless, about three-fourths of studies had eligibility criteria which would likely lead to the direct and/or indirect exclusion of adults with intellectual disability. Our findings suggest substantial cause for concern that adults with intellectual disability experience widespread exclusion from NIH-funded clinical trials-exclusion that may lack appropriate justification and assessment. Consequently, this group is denied equal access to the potential benefits of scientific discovery. We provide recommendations for approaches to include adults with intellectual disability.

Exclusion of older adults from clinical trials in cancer-related pain

Pain is one of the most common symptoms in cancer patients including older adults. The objective of this study was to evaluate the enrollment criteria that can limit the inclusion of older adults in clinical trials concerning cancer-related pain (CRP). The study included 356 trials registered with ClinicalTrials.gov. Our primary outcome measures were the proportion of trials that excluded patients based on upper age limits (80 years of age or less), strict organ-specific exclusion criteria, broad and imprecise criteria, and inadequate performance score. One hundred and twenty-six trials (35.4%) had upper age limits. Strict exclusion criteria were used in 95 (26.7%) trials. Broad and imprecise exclusion criteria were listed in 57 (16.2%) trials. Low performance score was used as an exclusion criterion in 4 trials (1.1%). Overall, in 241 trials (67.7%) there was either an upper age limit or at least one strict or broad and imprecise exclusion criterion, or a criterion involving the performance status. The odds of excluding older adults were significantly higher in certain neoplasm types, study objectives, intervention types, and center locations. In conclusion, considerable proportion of recent clinical trials concerning CRP either explicitly exclude older adults or create high risk of such exclusion which substantially limits the evidence base for the treatment of such patients in clinical practice. Sponsors and investigators should consider careful modification of the enrollment criteria to improve the inclusion of older individuals who make up the major proportion of cancer patients population.

Age Demographics of Subjects Enrolled in Global, Interventional Phase 3 Melanoma Clinical Trials

Background

Melanoma is a skin cancer with a rising worldwide incidence of just over 280,000 individuals with the greatest burden of illness in European, New Zealander, and Australian populations. Patients are diagnosed with melanoma with the mean and median ages being 65 and 59 years old, respectively. Phase 3 trials not only provide a wide representation of the target population but also study the efficacy for a certain intervention.

Objective

The objective of this literature review is to analyze patient demographics of phase 3 trials for melanoma and identify if there is a true disparity between the clinical trial age demographics and the natural epidemiological age demographics.

Data Sources

The authors conducted a search on clinicaltrials.gov, a publicly available resource that lists clinical trials and their data. The reported mean and median ages for each trial were extracted after determining if each trial meets our inclusion criteria. Weighted mean and median ages were calculated using an online calculator.

Data Summary

Data from 35 trials were evaluated with 30 trials reporting a weighted mean age of 55.85 years and 5 trials reporting a weighted median age of 55.14 years.

Conclusion

Based on the results, melanoma clinical trials enroll patients who are younger than the epidemiological mean and median ages. Due to this underrepresentation of the elderly patients with melanoma, clinical trials may provide limited application for the use of their results.

Impact of renal dysfunction and acute kidney injury on outcome in elderly patients with acute coronary syndrome undergoing percutaneous coronary intervention

BACKGROUND

Chronic kidney disease is common in patients admitted with acute coronary syndrome and its prevalence dramatically increases with age. Understanding the determinants of adverse outcomes in this extremely high-risk population may be useful for the development of specific treatment strategies and planning of secondary prevention modalities.

AIM

The aim of this study was to assess the impact of baseline renal function and acute kidney injury on one-year outcome of elderly patients with acute coronary syndrome treated with percutaneous coronary intervention.

METHODS

Patients aged 75 years and older with acute coronary syndrome undergoing successful percutaneous coronary intervention were selected among those enrolled in three Italian multicentre studies. Based on the baseline estimated glomerular filtration rate (eGFR) calculated using the Cockcroft-Gault formula ([(140-age) × body weight × 0.85 if female]/(72 × serum creatinine)* 1.73 m2 of body surface area), patients were classified as having none or mild (eGFR ≥60 ml/min/1.73 m2), moderate (eGFR 30-59 ml/min/1.73 m2) or severe (eGFR <30 ml/min/1.73 m2) renal dysfunction. Acute kidney injury was defined according to the Acute Kidney Injury Network classification. All-cause and cardiovascular mortality, non-fatal myocardial infarction, rehospitalisation for cardiovascular causes, stroke and type 2, 3 and 5 Bleeding Academic Research Consortium bleedings were analysed up to 12 months.

RESULTS

A total of 1904 patients were included. Of these, 57% had moderate and 11% severe renal dysfunction. At 12 months, patients with renal dysfunction had higher rates (P < 0.001) of all-cause (4.5%, 7.5% and 17.8% in patients with none or mild, moderate and severe renal dysfunction, respectively) and cardiovascular mortality (2.8%, 5.2% and 10.2%, respectively). After multivariable adjustment, severe renal dysfunction was associated with a higher risk of all-cause (hazard ratio (HR) 2.86, 95% confidence interval (CI) 1.52-5.37, P = 0.001) and cardiovascular death (HR 3.11, 95% CI 1.41-6.83, P = 0.005), whereas non-fatal events were unaffected. Acute kidney injury incidence was significantly higher in ST-elevation myocardial infarction versus non-ST-elevation acute coronary syndrome patients (11.7% vs. 7.8%, P = 0.036) and in those with reduced baseline renal function (P < 0.001), and it was associated with increased mortality independently from baseline renal function and clinical presentation.

CONCLUSIONS

Baseline renal dysfunction is highly prevalent and is associated with higher mortality in elderly acute coronary syndrome patients undergoing percutaneous coronary intervention. Acute kidney injury occurs more frequently among ST-elevation myocardial infarction patients and those with pre-existing renal dysfunction and is independently associated with one-year mortality.

An Update on Medication Use in Older Adults: a Narrative Review

PURPOSE OF REVIEW

The global phenomenon of population aging is impacting the health and care needs of society. The use of medications by older adults is acknowledged to be the most common form of medical intervention for many acute and chronic conditions and prescribing in this population continues to increase. In this narrative review, we summarise the age-related factors that should be considered when prescribing for older adults, address some of the perennial challenges related to medicine use in older people, and highlight important emerging research in this area.

RECENT FINDINGS

A range of age-related factors should be considered when prescribing for older adults. However, the evidence base still lacks data pertaining to older adults due to their continued under-representation in clinical trials. Multimorbidity, polypharmacy, and inappropriate prescribing continue to remain prevalent among older adults, although recent research has been focused on the development and evaluation of complex interventions to address these challenges.

SUMMARY

Further high-quality studies of interventions to improve and support medication use in older adults are needed, ensuring that older adults are well represented in such trials and consideration is given to the measurement of patient- and provider-focused outcomes.

Impact of differences in acute respiratory distress syndrome randomised controlled trial inclusion and exclusion criteria: systematic review and meta-analysis

BACKGROUND

Control-arm mortality varies between acute respiratory distress syndrome (ARDS) RCTs.

METHODS

We systematically reviewed ARDS RCTs that commenced recruitment after publication of the American-European Consensus (AECC) definition (MEDLINE, Embase, and Cochrane central register of controlled trials; January 1994 to October 2020). We assessed concordance of RCT inclusion criteria to ARDS consensus definitions and whether exclusion criteria are strongly or poorly justified. We estimated the proportion of between-trial difference in control-arm 28-day mortality explained by the inclusion criteria and RCT design characteristics using meta-regression.

RESULTS

A literature search identified 43 709 records. One hundred and fifty ARDS RCTs were included; 146/150 (97.3%) RCTs defined ARDS inclusion criteria using AECC/Berlin definitions. Deviations from consensus definitions, primarily aimed at improving ARDS diagnostic certainty, frequently related to duration of hypoxaemia (117/146; 80.1%). Exclusion criteria could be grouped by rationale for selection into strongly or poorly justified criteria. Common poorly justified exclusions included pregnancy related, age, and comorbidities (infectious/immunosuppression, hepatic, renal, and human immunodeficiency virus/acquired immunodeficiency syndrome). Control-arm 28-day mortality varied between ARDS RCTs (mean: 29.8% [95% confidence interval: 27.0-32.7%; I²=88.8%; τ²=0.02; P<0.01]), and differed significantly between RCTs with different Pao₂:FiO₂ ratio inclusion thresholds (26.6-39.9 kPa vs <26.6 kPa; P<0.01). In a meta-regression model, inclusion criteria and RCT design characteristics accounted for 30.6% of between-trial difference (P<0.01).

CONCLUSIONS

In most ARDS RCTs, consensus definitions are modified to use as inclusion criteria. Between-RCT mortality differences are mostly explained by the Pao₂:FiO₂ ratio threshold within the consensus definitions. An exclusion criteria framework can be applied when designing and reporting exclusion criteria in future ARDS RCTs.

Safety and efficacy of very short dual antiplatelet therapy followed by P2Y12 inhibitor monotherapy in older patients undergoing percutaneous coronary intervention: meta-analysis of randomised controlled trials

BACKGROUND

older patients undergoing percutaneous coronary intervention (PCI) represent a growing population sharing both a high ischemic and bleeding risk. Dual antiplatelet therapy (DAPT) reduces the incidence of thrombotic events but exposes patients to an increased risk of bleeding and subsequent mortality. Its optimal duration after PCI remains unclear.

OBJECTIVE

to assess the impact of short-duration DAPT on both bleeding and ischemic events in the specific population of older patients undergoing PCI.

METHODS

we performed a meta-analysis of randomised controlled trials comparing the safety and efficacy of standard versus very short duration (≤ 3 months, followed by P2Y12 inhibitor monotherapy) DAPT after PCI with a drug-eluting stent in older patients.

RESULTS

four studies, representing 8,961 older patients, were finally included. Compared with standard duration, short-duration DAPT was associated with similar rates of major bleeding (relative risks, RR 0.70 [0.47; 1.05]) and the composite efficacy endpoint (RR 0.85 [0.63; 1.14]). There was a high level of heterogeneity between the studies (I2 = 68%) regarding major bleeding.

CONCLUSION

our meta-analysis suggests that short DAPT may be a valid option in older patients after PCI but it also highlights the need for specific studies in such patients on optimal duration of antiplatelet therapy.

Comorbidities and Percutaneous Coronary Intervention in Elderly Patients with Acute Coronary Syndrome

Aim. To assess comorbidities in elderly patients with acute coronary syndrome (ACS) and to analyze patient subgroups with different treatment strategies in the Regional Vascular Center (RVC).

Material and methods. The prospective study included 205 patients with confirmed ACS 75 years and older, the mean age was 81±4.9 years, and 68% were women. ST segment elevation myocardial infarction (STEMI) was diagnosed in 46 (22.4 %) patients, non-ST segment elevation myocardial infarction (NSTEMI) was diagnosed in 159 (77,6 %) patients. The Charlson Comorbidity Index (CCI) was calculated in every patient. Early outcomes were defined as those assessed during hospital stay. Late outcomes were assessed at 6 months after the discharge using phone calls and/or clinic visits. All patients provided written informed consent.

Results. Percutaneous coronary intervention (PCI) was performed in 42% of patients. In patients with STEMI and NSTEMI PCI was performed in 73% and 32%, respectively. Mean CCI score was 7.9 points: 7.6 points in men and 8.04 in women. Patients with STEMI had higher CCI score than NSTEMI patients (p<0.01): 8.1 points and 7.1 points, respectively. Patients who underwent PCI had lower CCI score (7.2 points) than patients in non-PCI group (8.2 points; p<0.05). Patients with STEMI in PCI and non-PCI groups had significant difference in CCI score (p<0.05): 7.4 and 8.4 points, respectively. Mean CCI score in patients who died in hospital was 8.5 while discharged patients had 7.6 points (p<0.01). In 6 months 13 patients (6.3%) died, their mean age was 84.9 years, mean CCI was 9 points, PCI was performed in 3 (23%) patients.

Conclusions. Elderly patients with ACS had high comorbidity level assessed by CCI score. Higher CCI score was associated with PCI non-performance in elderly patients. Elderly patients with STEMI had higher CCI score than patients with NSTEMI which was significantly associated with PCI non-performance. Patients who died in hospital or in 6 months after the ACS onset had higher CCI score than other elderly patients with ACS.

Meta-analysis of light and circadian timekeeping in rodents

We conducted a meta-analysis of papers published over the past half-century (1964-2017) that quantified the phase-shifting effects of timed light exposure on rodent locomotor rhythms. Descriptive statistics were tabulated in order to explore the extent to which these studies were generalizable across species, sex, age, circadian timing, and light sources. Attempts at understanding photic resetting were primarily targeted at younger male animals, with particular emphases placed on characterizing the pacemaker systems of C57BL/6 mice and Syrian hamsters during the parts of their subjective night most sensitive to delivery of white-fluorescent light. With subsequent analyses restricted to these rodent models, we then assessed the relationship between luminous exposure (via broadspectrum emission) and phase-shifting through a series of linear regressions. Monotonically increasing illuminance-response functions were noted at most circadian times surveyed. In the aggregate, our results show that previous research conducted on light's regulation of circadian timekeeping has been skewed in design with respect to several important biological variables. This bias might limit translation of phototherapy-relevant data to women and older individuals.

Inclusion of Older People Reflective of Real-World Clinical Practice in Cardiovascular Drug Trials

Background

Underrepresentation of older people in clinical trials remains. This study aimed to examine the inclusion of older people and associated safety and efficacy reports from clinical trials of new molecular entities for cardiovascular disease indications since commencement of the US Food and Drug Administration Drug Trial Snapshot (DTS) Program. The DTS provides concise information on participants included in clinical trials supporting US Food and Drug Administration approval of new drugs.

Methods and Results

A cross‐sectional analysis between January 1, 2015 and April 30, 2019 of DTS data including approval date, indication, number of trials and participants, age distribution, efficacy, and safety statements was conducted. Participation‐to‐prevalence ratio (PPR) was used to describe representation of older participants in trials relative to disease population. Efficacy and safety statements regarding age were compared with drug prescribing information. A total of 72 079 participants from 10 DTS reports were identified and 39 625 (55.0%) were aged ≥65 years old. Overall, 63.6% of cardiovascular disease DTS reports were representative of people aged ≥65 years old for specific cardiovascular disease conditions. Underrepresentation was observed in 4 DTS: 2 for heart failure (PPR 0.48 and 0.62), 1 for pulmonary arterial hypertension (PPR 0.72), and 1 for venous thromboembolism (PPR 0.38). Participants in clinical trials for new drugs for the treatment of atrial fibrillation (PPR 0.99 and 1.21) and hypercholesterolemia (PPR 0.84 and 0.97) were reflective of the older population for these diseases. An increased risk of adverse events in older participants was reported in 40% DTS safety statements but no differences were reported in the drug product information.

Conclusions

Despite the fact that >60% of cardiovascular disease trial participants for new molecular entities included in the DTS program were representative of the older population in real‐world clinical practice, concerns remain for conditions including heart failure or venous thromboembolism. Drug product information safety statements regarding age differences in adverse events were not reflective of trial findings. An increased directive is needed to facilitate the generation of real‐world evidence and appropriate reporting within drug product information for these potentially at‐risk patient populations.

Global, regional, and national burden of ischemic heart disease and its attributable risk factors, 1990-2017: results from the global Burden of Disease Study 2017

Aims

The aim of this study was to estimate the burden and risk factors for ischaemic heart disease (IHD) in 195 countries and territories from 1990 to 2017.

Methods and results

Data from the Global Burden of Disease Study 2017 were used. Prevalence, incidence, deaths, years lived with disability (YLDs), and years of life lost (YLLs) were metrics used to measure IHD burden. Population attributable fraction was used to estimate the proportion of IHD deaths attributable to potentially modifiable risk factors. Globally, in 2017, 126.5 million [95% uncertainty interval (UI) 118.6 to 134.7] people lived with IHD and 10.6 million (95% UI 9.6 to 11.8) new IHD cases occurred, resulting in 8.9 million (95% UI 8.8 to 9.1) deaths, 5.3 million (95% UI 3.7 to 7.2) YLDs, and 165.0 million (95% UI 162.2 to 168.6) YLLs. Between 1990 and 2017, despite the decrease in age-standardized rates, the global numbers of these burden metrics of IHD have significantly increased. The burden of IHD in 2017 and its temporal trends from 1990 to 2017 varied widely by geographic location. Among all potentially modifiable risk factors, age-standardized IHD deaths worldwide were primarily attributable to dietary risks, high systolic blood pressure, high LDL cholesterol, high fasting plasma glucose, tobacco use, and high body mass index in 2017.

Conclusion

Our results suggested that IHD remains a major public health challenge worldwide. More effective and targeted strategies aimed at implementing cost-effective interventions and addressing modifiable risk factors are urgently needed, particularly in geographies with high or increasing burden.

Cardiovascular rehabilitation in patients aged 70-year-old or older: benefits on functional capacity, physical activity and metabolic profile in younger vs. older patients

Background

The benefits of exercise-based cardiac rehabilitation (EBCR) programs in post-acute myocardial infarction (AMI) patients have been demonstrated. Our aim was to assess the impact of EBCR in ≥ 70-years-old vs. younger post-AMI patients.

Methods

We retrospectively evaluated patients who underwent a supervised EBCR protocol, twice a week during 6-12 weeks. We evaluated changes in several outcomes based on pre- and post-CRP assessments.

Results

Of a total of 1607 patients, 333 (21%) were ≥ 70-years-old. After the EBCR, an overall improvement on functional capacity, daily physical activity, lipid profile, body mass index, glycated hemoglobin (HbA1c), N-terminal pro-brain natriuretic peptide (NT-pro-BNP) and C-reactive protein was observed in both younger and older patients (P < 0.05). Older patients showed a smaller benefit on the increment of daily physical activity and lipid profile improvement, but a larger reduction in NT-pro-BNP. In the multivariate analysis, only improvements on daily physical activity and HbA1c were dependent on age.

Conclusion

As their younger counterparts, older patients, significantly improved functional capacity, metabolic parameters and level of daily physical activity after EBCR.

Ticagrelor monotherapy beyond one month after PCI in ACS or stable CAD in elderly patients: a pre-specified analysis of the GLOBAL LEADERS trial

AIMS

Antiplatelet treatment in the elderly post percutaneous coronary interventions (PCI) remains a complex issue. Here we report the results of the pre-specified subgroup analysis of the GLOBAL LEADERS trial evaluating the long-term safety and cardiovascular efficacy of ticagrelor monotherapy among patients categorised according to the pre-specified cut-off value of 75 years of age.

METHODS AND RESULTS

This was a pre-specified analysis of the randomised GLOBAL LEADERS trial (n=15,991), comparing 23-month ticagrelor monotherapy (after one month of DAPT) with the reference treatment (12-month DAPT followed by 12 months of aspirin). Among elderly patients (>75 years; n=2,565), the primary endpoint (two-year all-cause mortality or new Q-wave core lab-adjudicated myocardial infarction [MI]) occurred in 7.2% and 9.4% of patients in the ticagrelor monotherapy and the reference group, respectively (hazard ratio [HR] 0.75, 95% confidence interval [CI]: 0.58-0.99, p=0.041; pint=0.23); BARC-defined bleeding type 3/5 occurred in 5.2% and 4.1%, respectively (HR 1.29, 95% CI: 0.89-1.86; p=0.180; pint=0.06). The elderly with stable CAD had a higher rate of BARC 3/5 type bleeding (HR 2.05, 95% CI: 1.18-3.55) with ticagrelor monotherapy versus the reference treatment (pint=0.02). Elderly patients had a lower rate of definite or probable stent thrombosis (ST) with ticagrelor monotherapy (0.4% vs 1.4%, p=0.015, pint=0.01), compared with the reference group.

CONCLUSIONS

In this pre-specified, exploratory analysis of the overall neutral trial, there was no differential treatment effect of ticagrelor monotherapy (after one-month dual therapy with aspirin) found in elderly patients undergoing PCI with respect to the rate of the primary endpoint of all-cause death or new Q-wave MI. The lower rate of ST in the elderly with ticagrelor monotherapy is hypothesis-generating. ClinicalTrials.gov identifier: NCT01813435.

Glucocorticoid-trials in rheumatoid arthritis mostly study representative real-world patients: A systematic review and meta-analysis

OBJECTIVE

Randomized controlled trials (RCTs) are considered the gold standard in clinical research due to credible causality. Their results, however, may not be generalizable to real-world populations. While glucocorticoids (GCs) remain a mainstay of rheumatoid arthritis (RA) treatment, it is unclear whether the results of GC-RCTs are generalizable to current real-world RA patients.

METHODS

MEDLINE was searched for RCTs and, as comparators, cohort studies (CSs) in RA evaluating systemic GCs. Random-effects meta-analyses were performed for descriptive baseline characteristics (including general demographics, comorbidities, and disease activity) that have been shown to be able to modify the benefit-risk-ratio of various RA therapeutics. These meta-analyses were stratified by study type (RCT and CS). Stratified estimates were subsequently compared. Further sensitivity analyses were performed stratifying by disease duration.

RESULTS

56 RCTs (7053 participants) and 10 CSs (14,688 participants) were included. 12 characteristics were reported frequently enough to allow for comparative analysis. In 10/12 characteristics (83%), RCT estimates did not appear to differ from CS estimates. However, RCT participants were younger (-4.7 years [95% CI -7.2 to -2.1]; p < 0.001) and had higher erythrocyte sedimentation rates (11.8 mm/h [5.7 to 17.8]; p < 0.001) than CS participants. Comorbidities could not be assessed due to insufficient reporting.

CONCLUSION

Our findings suggest that evidence from GC trials in RA is of acceptable generalizability to current real-world patients - especially compared to findings from biologic agents in RA. However, RCT participants were younger than real-world patients, potentially limiting the generalizability of trial results to elderly patients.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO (CRD42019134675).

Including older rural adults in research: Practical guidance for addressing the NIH Inclusion Across the Lifespan policy

INTRODUCTION

The NIH Inclusion Across the Lifespan policy has implications for increasing older adult (OA) participation in research. This study aimed to understand influential factors and facilitators to rural OA research participation.

METHODS

Thirty-seven rural adults aged ≥66 years participated in focus groups in community centers in four Oregon "non-metro" counties. Transcribed discussions were coded using open-axial coding by an interdisciplinary analytical team.

RESULTS

Ages were 66-96 (mean 82.2) years. Majority were women (64%) and white (86%). Primary, interrelated discussion themes were Motivation and Facilitators, Perceptions of Research, and Barriers to Research Participation. Participants were motivated to engage in research because they believed research had implications for improved longevity and quality of life and potentially benefited future generations. Motivational factors influencing participation included self-benefit and improving others' lives, opportunities to socialize and learn about current research, research transparency (funding, time commitment, and requirements), and financial compensation. Perceptions influencing trustworthiness in research included funding source (industry/non-industry) and familiarity with the research institution. Barriers to research participation included transportation and concern about privacy and confidentiality. Suggestions for making research participation easier included researchers coming to rural communities and meeting participants in places where OAs gather and providing transportation and hotel accommodations.

CONCLUSION

Lessons learned offer practical guidance for research teams as they address the new NIH Inclusion Across the Lifespan policy. Including OAs in research in ways that motivate and facilitate participation will be critical for a robust representation across the lifespan and in tailoring treatments to the specific needs of this population.

Association of Receiving Multiple, Concurrent Fracture-Associated Drugs With Hip Fracture Risk

IMPORTANCE

Many prescription drugs increase fracture risk, which raises concern for patients receiving 2 or more such drugs concurrently. Logic suggests that risk will increase with each additional drug, but the risk of taking multiple fracture-associated drugs (FADs) is unknown.

OBJECTIVE

To estimate hip fracture risk associated with concurrent exposure to multiple FADs.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used a 20% random sample of Medicare fee-for-service administrative data for age-eligible Medicare beneficiaries from 2004 to 2014. Sex-stratified Cox regression models estimated hip fracture risk associated with current receipt of 1, 2, or 3 or more of 21 FADs and, separately, risk associated with each FAD and 2-way FAD combination vs no FADs. Models included sociodemographic characteristics, comorbidities, and use of non-FAD medications. Analyses began in November 2018 and were completed April 2019.

EXPOSURE

Receipt of prescription FADs.

MAIN OUTCOMES AND MEASURES

Hip fracture hospitalization.

RESULTS

A total of 11.3 million person-years were observed, reflecting 2 646 255 individuals (mean [SD] age, 77.2 [7.3] years, 1 615 613 [61.1%] women, 2 136 585 [80.7%] white, and 219 579 [8.3%] black). Overall, 2 827 284 person-years (25.1%) involved receipt of 1 FAD; 1 322 296 (11.7%), 2 FADs; and 954 506 (8.5%), 3 or more FADs. In fully adjusted, sex-stratified models, an increase in hip fracture risk among women was associated with the receipt of 1, 2, or 3 or more FADs (1 FAD: hazard ratio [HR], 2.04; 95% CI, 1.99-2.11; P < .001; 2 FADs: HR, 2.86; 95% CI, 2.77-2.95; P < .001; ≥3 FADs: HR, 4.50; 95% CI, 4.36-4.65; P < .001). Relative risks for men were slightly higher (1 FAD: HR, 2.23; 95% CI, 2.11-2.36; P < .001; 2 FADs: HR, 3.40; 95% CI, 3.20-3.61; P < .001; ≥3 FADs: HR, 5.18; 95% CI, 4.87-5.52; P < .001). Among women, 2 individual FADs were associated with HRs greater than 3.00; 80 pairs of FADs exceeded this threshold. Common, risky pairs among women included sedative hypnotics plus opioids (HR, 4.90; 95% CI, 3.98-6.02; P < .001), serotonin reuptake inhibitors plus benzodiazepines (HR, 4.50; 95% CI, 3.76-5.38; P < .001), and proton pump inhibitors plus opioids (HR, 4.00; 95% CI, 3.56-4.49; P < .001). Receipt of 1, 2, or 3 or more non-FADs was associated with a small, significant reduction in fracture risk compared with receipt of no non-FADs among women (1 non-FAD: HR, 0.93; 95% CI, 0.90-0.96; P < .001; 2 non-FADs: HR, 0.84; 95% CI, 0.81-0.87; P < .001; ≥3 non-FADs: HR, 0.74; 95% CI, 0.72-0.77; P < .001).

CONCLUSIONS AND RELEVANCE

Among older adults, FADs are commonly used and commonly combined. In this cohort study, the addition of a second and third FAD was associated with a steep increase in fracture risk. Many risky pairs of FADs included potentially avoidable drugs (eg, sedatives and opioids). If confirmed, these findings suggest that fracture risk could be reduced through tighter adherence to long-established prescribing guidelines and recommendations.

One-year survival and admission to hospital for cardiovascular events among older residents of long-term care facilities who were prescribed intensive- and moderate-dose statins

BACKGROUND

Guidance from randomized clinical trials about the ongoing benefits of statin therapies in residents of long-term care facilities is lacking. We sought to examine the effect of statin dose on 1-year survival and admission to hospital for cardiovascular events in this setting.

METHODS

We conducted a retrospective cohort study using population-based administrative data from Ontario, Canada. We identified 21 808 residents in long-term care facilities who were 76 years of age and older and were prevalent statin users on the date of a full clinical assessment between April 2013 and March 2014, and categorized residents as intensive- or moderate-dose users. Treatment groups were matched on age, sex, admission to hospital for atherosclerotic cardiovascular disease, resident frailty and propensity score. Differences in 1-year survival and admission to hospital for cardiovascular events were measured using Cox proportional and subdistribution hazard models, respectively.

RESULTS

Using propensity-score matching, we included 4577 well-balanced pairs of residents who were taking intensive- and moderate-dose statins. After 1 year, there were 1210 (26.4%) deaths and 524 (11.5%) admissions to hospital for cardiovascular events among residents using moderate-dose statins compared with 1173 (25.6%) deaths and 522 (11.4%) admissions to hospital for cardiovascular events among those taking intensive-dose statins. We found no significant association between prevalent use of intensive-dose statins and 1-year survival (hazard ratio [HR] 0.97, 95% confidence interval [CI] 0.90 to 1.05) or 1-year admission to hospital for cardiovascular events (HR 0.99, 95% CI 0.88 to 1.12) compared with use of moderate-dose statins.

INTERPRETATION

The rates of mortality and admission to hospital for cardiovascular events at 1 year were similar between residents in long-term care taking intensive-dose statins compared with those taking moderate-dose statins. This lack of benefit should be considered when prescribing statins to vulnerable residents of long-term care facilities who are at potentially increased risk of statin-related adverse events.

Association Between Participant Retention and the Proportion of Included Elderly People in Rheumatology Trials: Results From a Series of Exploratory Meta-Regression Analyses

OBJECTIVE

The elderly, a population defined by an age of ≥65 years, are underrepresented in rheumatology trials, possibly due to investigators' concerns of increased premature discontinuations in higher age groups. The present study was undertaken to evaluate whether the proportion of included elderly individuals (PE) is independently associated with participant retention in rheumatology trials.

METHODS

Medline was searched for randomized controlled trials (RCTs) in rheumatoid arthritis (RA) and osteoarthritis (OA) of any intervention (years 2016 and 2017). PE was either extracted from the research manuscript or estimated from an assumed (truncated) normal distribution. We used mixed-effects meta-regression models including several covariates to assess whether there is an independent association between PE and participant retention. Using sensitivity analyses, we evaluated whether associations were connected to attrition due to lack of efficacy (LoE) or adverse events (AE).

RESULTS

In total, 243 RCTs comprising >48,000 participants were included. Pooled participant retention was 88%. PE was not associated with retention in the unadjusted (P = 0.97) or adjusted (all: P ≥ 0.14) models. Of all covariates, only study duration and type of intervention were associated with retention (both: P < 0.001). Post hoc analyses allowing for interaction revealed a small but statistically significant positive association between PE and retention in pharmacologic interventions and a negative association in physical/physiotherapeutic interventions (overall P for interaction = 0.05). No associations were found for PE and attrition due to LoE or AE.

CONCLUSION

Participant retention in RA and OA trials is high and not associated with PE. These findings should motivate investigators to include more elderly participants in rheumatology trials.

Protection by exclusion? The (lack of) inclusion of adults who lack capacity to consent to research in clinical trials in the UK

BACKGROUND

Around two million adults in the UK have significantly impaired decision-making capacity. However, there are concerns that this population is under-represented in research, due in part to the challenges around obtaining consent. Under-representation of populations denies those who would have wanted to participate the opportunity to make a contribution to society, but also fails to generate results that are applicable to them. Consequently, the evidence base for their care is poorer than for other populations. We recently published in this journal an analysis of Participant Information Sheets provided to consultees and legal representatives of adults who lack capacity and noted the small number of trials designed to include adults who lack capacity. In order to understand how many adults who lack capacity to consent are actually enrolled in clinical trials, we further explored how many of the participants lacked capacity, and who acted as a consultee or legal representative on their behalf.

MAIN TEXT

The ISRCTN registry was searched for UK clinical trials in conditions commonly associated with cognitive impairment that were designed to include (or not exclude) adults who lack capacity to consent. Details about participants and capacity status were obtained from published data or directly from the trial teams. Of the 80 retrieved clinical trials that had completed in the previous 3 years, we identified 15 which included adults who lack capacity to consent. Data regarding participants' capacity status were not available for five trials. Where capacity was reported, 5-100% participants lacked capacity to consent. Trials predominantly utilised personal consultees/legal representatives; however, 39% (634/1631) of participants required a professional to act as consultee/legal representative.

CONCLUSIONS

Only a small number of trials including adults who lacked capacity were identified. The majority of participants were represented by a personal consultee/legal representative; however, between 21 and 100% of participants across five trials required the involvement of a professional, suggesting it is not uncommon. Data relating to capacity status were rarely reported, potentially masking the under-representation of adults who lack capacity. The findings may help researchers and funders target resources towards studies involving under-represented populations to increase the much-needed evidence base for their care and treatment.

Women in clinical trials: a review of policy development and health equity in the Canadian context

Health equity in pharmaceutical research is concerned with creating equal opportunities for men and women to partake in clinical trials. Equitable representation is imperative for determining the safety, effectiveness, and tolerance of drugs for all consumers. Historically, women have been excluded from participating in clinical research leading to a lack of knowledge regarding drug effects and their consequences. This paper examines the changes made since the implementation of Canadian policies on the representation of women in clinical trials, the analysis of sex and gender, as well as the discourses that are prominent among researchers. A feminist ethics framework is used to examine the structures that endeavor to elucidate women's involvement in trials, as experienced under extensive patriarchal history. Scholarly literature and Canadian government policy documents are used to explore the development of clinical trials as pertaining to sex and gender. Findings suggest that women continue to be underrepresented or excluded from important research, highlighting ongoing ethical and justice concerns. Improvement recommendations for policies are outlined.

How Does the Presence of Diabetes Affect the Course of Acute Coronary Syndrome in Elderly Patients in Actual Clinical Practice?

The number of elderly patients with diabetes mellitus (DM) is constantly growing in general population. Accordantly, we have the growth of such patients in the group of acute coronary syndrome (ACS).

Aim.To compare clinical characteristics of the elderly patient (>75 years old) with and without DM.

Material and methods. This retrospective study included 1133 ACS patients who were aged ≥75 years and admitted to the City Clinical Hospital №1 from 01.01.2015 to 31.12.2016. Median age was 80 years, 66% were women. We analyzed 4 patient subgroups: Group 1 – 105 patients with ST-segment elevation myocardial infarction (STEMI) and DM, Group 2 – 254 STEMI patients without DM, Group 3 – 222 non-STEMI patients with DM and Group 4 – 552 non-STEMI patients without DM. We used Student’s t-test and c2 tests to find significant difference between pairs of groups.

Results. Median age of patients in 4 groups was 80, 81, 81 and 80 years (p>0.05), age variance was 75-100 years. DM was found in 29% of all elderly patients with no difference between STEMI and non-STEMI groups. STEMI and non-STEMI patients with DM were more likely women. NonSTEMI patients with DM more often had hypertension, previous stroke, lower median Hb (121 vs 127 g/l; p<0.001). Angiography data demonstrated more often three-vessel disease (43% vs 29.7%) and less one-vessel disease (15% vs 25.6%; p<0.05) between groups 3 and 4. Glomerular filtration rate (GFR) <60 ml/min/1.73 m2 occurred in 74%, 73%, 77% and 74% in patients of 4 groups (p>0,05), but GFR<45 ml/min/1.73 m2 was more prevalent in patients with DM than without DM: 45%, 39%, 45%, 36% in 4 groups. Finally, mortality rates didn’t demonstrate significant difference between DM and non-DM patients with STEMI (10% vs 13%; p>0.05) and non-STEMI (7% vs 7%) groups.

Conclusion. DM is associated with ACS approximately in one third of the elderly patients and is not associated with its type (STEMI or non-STEMI). In STEMI and non-STEMI patients the female sex and GFR level <45 ml/min/1.73 m2 were associated with DM. In non-STEMI group multi-vessel disease and presence of hypertension and previous stroke were associated with DM. We didn’t find any difference between mortality in elderly patients with and without DM. 

Adequacy of Inclusion of Older Adults in NIH-Funded Phase III Clinical Trials

In the United States, the population aged 65 and older is rapidly growing, and this group uses more healthcare resources and has unique healthcare needs that do not exist in younger populations. However, it was reported that older adults are excluded or underrepresented in clinical trials for several diseases. We examined phase III clinical trials funded by the National Institutes of Health found in www.clinicaltrials.gov from 1965 to 2015 that addressed top causes for hospitalization and/or disability-adjusted life years in older adults: congestive heart failure (n = 45), cardiac dysrhythmias (n = 24), coronary atherosclerosis (n = 106), heart attack (n = 76), stroke (n = 113), chronic obstructive pulmonary disease (n = 14), pneumonia (n = 48), lung cancer (n = 117), prostate cancer (n = 65), and osteoarthritis (n = 15). We then analyzed the representation of older adults in these studies. We found that 33% of studies had arbitrary upper age limits, and 67% of studies reported mean and/or median ages that skewed younger than expected for the disease or condition of interest. Beyond explicit exclusion by age, older adults were often implicitly excluded based on various comorbid conditions such as polypharmacy/concomitant medication (37%) or cardiac issues (30%). We conclude that outcomes of these trials may not be fully generalizable to the general population of older adults. J Am Geriatr Soc 67:218-222, 2019.

The 5Ts: Preliminary Development of a Framework to Support Inclusion of Older Adults in Research

BACKGROUND/OBJECTIVES

To address the underrepresentation of older adults in clinical research, the National Institutes of Health will require investigators to include individuals across the lifespan. As investigators from other fields endeavor to recruit participants who are more representative of the patient population, geriatricians may have the opportunity to influence a broad range of research studies in older adults. Our aims were to elicit challenges to inclusion of older adults in clinical research and to develop a preliminary framework for communicating these challenges to non-geriatrics-trained researchers.

DESIGN

Communication framework development.

SETTING

Academic hospital and Veterans Affairs Medical Center.

PARTICIPANTS

Nongeriatrician researchers and staff, aging research experts.

MEASUREMENTS

Interviews were used to elicit challenges nongeriatrician investigators and research staff experience when conducting research that includes older adults and then solicit experienced aging researchers' responses to these challenges.

RESULTS

Challenges described by nongeriatrician investigators included lack of knowledge, rigid study structures, and a disease-focused approach. Responses from our geriatrics experts included communicating practical advice for avoiding common pitfalls. Our resulting framework is the 5Ts: Target Population, Team, Tools, Time, and Tips to Accommodate. This tool complements the 5Ms (Mind, Mobility, Medications, Multicomplexity, and Matters Most to Me) model for geriatric care and emphasizes representation of the Target Population, building research Teams that include aging expertise, incorporating appropriate Tools for function and patient-reported outcomes, anticipating Time for longer study visits, and accommodating common needs with practical Tips. Limitations include convenience sampling and lack of formal qualitative thematic analysis.

CONCLUSION

Communicating with nongeriatrician researchers using the 5Ts may offer a practical approach to avoiding barriers to inclusion of older adults in research and complements an existing framework for communicating the value of geriatric medicine. Next steps in developing the 5Ts will be to include additional stakeholders (eg, national samples of nongeriatrician investigators, older adults and their families) and evaluating the impact of its implementation. J Am Geriatr Soc 67:342-346, 2019.

A Proposal for the Retrospective Identification and Categorization of Older People With Functional Impairments in Scientific Studies-Recommendations of the Medication and Quality of Life in Frail Older Persons (MedQoL) Research Group

When treating older adults, a main factor to consider is physical frailty. Because specific assessments in clinical trials are frequently lacking, critical appraisal of treatment evidence with respect to functional status is challenging. Our aim was to identify and categorize assessments for functional status given in clinical trials in older adults to allow for a retrospective characterization and indirect comparison of treatment evidence from these cohorts. We conducted 4 separate systematic reviews of randomized and nonrandomized controlled clinical trials in older people with hypertension, diabetes, depression, and dementia. All assessments identified that reflected functional status were analyzed. Assessments were categorized across 4 different functional status levels. These levels span from functionally not impaired, slightly impaired, significantly impaired, to severely impaired/disabled. If available from the literature, cut-offs for these 4 functioning levels were extracted. If not, or if the existing cut-offs did not match the predefined functional levels, cut-off points were defined by an expert group composed of geriatricians, pharmacists, pharmacologists, neurologists, psychiatrists, and epidemiologists using a patient-centered approach. We identified 51 instruments that included measures of functional status. Although some of the assessments had clearly defined cut-offs across our predefined categories, many others did not. In most cases, no cut-offs existed for slightly impaired or severely impaired older adults. Missing cut-offs or values to adjust were determined by the expert group and are presented as described. The functional status assessments that were identified and operationalized across 4 functional levels could now be used for a retrospective characterization of functional status in randomized controlled trials and observational studies. Allocated categories only serve as approximations and should be validated head-to-head in future studies. Moreover, as general standard, upcoming studies involving older adults should include and explicitly report functional impairment as a baseline characteristic of all participants enrolled.

Lower Prescription Rates in Centenarians with Heart Failure and Heart Failure and Kidney Disease Combined: Findings from a Longitudinal Cohort Study of Very Old Patients

BACKGROUND

Centenarians are considered as models of successful aging and represent a special group of patients. The aim of this study was to analyze heart failure epidemiology and treatment trajectories in centenarians compared to nonagenarians (90-99 years of age) and octogenarians (80-89 years of age) with heart failure and with heart failure and kidney disease combined.

METHODS

This cohort study used quarterly structured routine data from 1398 German insurants over 6 years prior to death (398 centenarians were compared with 500 nonagenarians and 500 octogenarians). Of those, 525 individuals were diagnosed with heart failure before death; 164 had heart failure and kidney disease combined. Generalized estimation equations were used to assess the association of diagnoses of heart failure and other diseases with medication prescriptions.

RESULTS

Across age groups, heart failure was significantly more prevalent in centenarians compared with octogenarians and nonagenarians. Prevalence of heart failure increased over time. Female sex [odds ratio (men) = 0.70, p = 0.024], kidney disease (odds ratio = 1.31, p < 0.001), and hypertension (odds ratio = 1.52, p < 0.001) were all associated with heart failure. Overall, heart failure treatment changed significantly over time with an increased prescription rate of loop diuretics and a decreased rate of renin-angiotensin-system inhibitors. Centenarians were significantly less likely to receive treatment with renin-angiotensin-system inhibitors, loop diuretics, or beta-blockers compared with nonagenarians and octogenarians. Furthermore, aldosterone inhibitors were seldom prescribed; If-channel and neprilysin inhibitors were not routinely used in our sample. For those with heart failure and kidney disease combined, our data revealed that the prevalence of kidney disease was lower in centenarians than in younger patients before death. However, differences in prescription rates across age groups were non-significant, although numerically large. Finally, half of the patients in all three age groups with heart failure and kidney disease received treatment with renin-angiotensin-system inhibitors; about two out of five patients received beta-blockers, while prescription rates of aldosterone inhibitors were low.

CONCLUSIONS

While heart failure prevalence shows a continuous increase with age, prescription rates are lower in centenarians, emphasizing the need for further studies considering the quality of care and outcomes in this patient population. Disease management programs and trials are needed to develop guidelines that address the medically challenging treatment for very old patients with comorbid heart failure and kidney disease.

Using Real-World Data to Extrapolate Evidence From Randomized Controlled Trials

Randomized controlled trials (RCTs) provide evidence for regulatory agencies, shape clinical practice, influence formulary decisions, and have important implications for patients. However, many patient groups that are major consumers of drugs are under-represented in randomized trials. We review three methods to extrapolate evidence from trial participants to different target populations following market approval and discuss how these could be implemented in practice to support regulatory and health technology assessment decisions. Although these methods are not a substitute for less restrictive pre-approval RCTs or rigorous observational studies when sufficient data are available in the post-approval setting, they can help to fill the evidence gap that exists in the early marketing period. Early evidence using real-world data and methods for extrapolating evidence should be reported with clear explanation of assumptions and limitations especially when used to support regulatory and health technology assessment decisions.

Elderly Patient Management Problems: Antithrombotic Therapy Selection Features. Clinical Case

The growing population of elderly people is the main «antithrombotic drugs consumer» because there is higher prevalence of thromboembolic diseases (acute coronary syndrome, venous thromboembolism, atrial fibrillation) among them than among younger people. Elderly people have high risks of both thromboembolic and bleeding complications associated with antithrombotic drugs using. Antithrombotic drug choice is based on individual careful estimation of the «risk/benefit» ratio. Sometimes real clinical practice gives us problems and questions, having no answers in any guidelines. Such a difficult clinical case of elderly patient management is presented in this article.