Tackling frailty and functional decline: Background of the action group A3 of the European innovation partnership for active and healthy ageing

Ageing populations represent a challenge to the sustainability of current healthcare systems. The need to balance these demographic changes with gains in healthy life years and quality of life (QoL) constitutes an additional challenge. Aware of this, the European Commission (EC) launched the European Innovation Partnership on Active and Healthy Ageing (EIPonAHA) in 2012. The EIPonAHA is an interdisciplinary and cross-sector initiative involving more than 3000 partners with two specific objectives: to increase the healthy life expectancy of Europeans by two years by 2020, while increasing their QoL. The initiatives of the EIPonAHA have been organized according to six thematic action groups (AGs), with the A3 group targeting areas relating to the prevention of functional decline and frailty. In addition to the good practices of partners, there are several on-going collaborative works. The involvement of the EC includes support through an elaborated research programme in which the Consumers, Health, Agriculture and Food Executive Agency (CHAFEA) and the Directorate-General for Communications Networks, Content and Technology (DG CONNECT) are the main funding bodies. Screening approaches and preventive interventions constitute most of the initiatives within the A3 AG. Partners are distributed across five sub-groups according to good practices: i) cognitive decline, ii) food and nutrition, iii) physical activity, iv) caregivers, and v) frailty and functional decline. Regular updates of the progression of both good practices and collaborative works are presented in A3 AG meetings. The 2017 meeting in Valencia, Spain, showcased in this paper, provides an up-to-date overview of the current status of A3 activities.

Effects of Exercise and Nutrition on the Coagulation System During Bedrest Immobilization

Immobilization in hospitalized medical patients or during simulation of spaceflight induced deconditioning has been shown to be associated with loss of muscle mass and bone. Resistance vibrating exercise (RVE) and/or high protein diet are countermeasures, which are capable of mitigating the adverse effects of immobilization. We investigated the effect of these countermeasures on the coagulation system. Two groups of volunteers, each of whom performed such countermeasures, were enrolled in the study. Volunteers, who did nothing while bed rested, served as controls. The berest and the intervention protocols were carried out at Clinique d' Investigation, MEDES, Toulouse, France. Eleven healthy men volunteered for this randomized crossover study. The subjects underwent 21 day of 6° head down bed rest (HDBR) followed by a washout period of 4 months. The first group followed an exercise schedule using resistance-vibrating exercise (RVE group). The second group also used the RVE but complemented it with high-protein supplement diet (NeX group). The third group only did bed rest. The highly sensitive methods calibrated automated thrombography (CAT) and thrombelastometry (TEM) were applied to monitor hemostatic changes. In all 3 groups, the hemostatic system shifted toward hypocoagulability during bed rest. For example, peak and thrombin formation velocity (VELINDEX) reduced in this period. Interestingly, a tendency toward hypercoagulation was observed during re-ambulation. In all 3 groups, ttPeak and StartTail were reduced, and Peak and VELINDEX (except in the RVE group) were significantly higher in relation to baseline values. Influence of bed rest on the coagulation system in the 2 groups performing countermeasures (RVE and NeX group) was the same as in the control bed-rested group. Clotting does not seem to be worsened by prolonged immobilization, or by countermeasures such as RVE/exercise or high-protein supplementation during immobilization. Therefore, only hospitalized medical patients at an elevated risk for thrombosis should be treated with anticoagulants. However, clinicians have to be aware that the re-ambulation period following immobilization might be associated with an elevated risk of thrombotic events.

[Catalogue of learning goals for pregraduate education in geriatric medicine. A recommendation of the German Geriatric Society (DGG), the German Society of Gerontology and Geriatrics (DGGG), the Austrian Society of Geriatrics and Gerontology (ÖGGG) and the Swiss Society of Geriatric Medicine (SFGG) on the basis of recommendations of the European Union of Medical Specialists Geriatric Medicine Section (UEMS-GMS) 2013]

Sound knowledge in the care and management of geriatric patients is essential for doctors in almost all medical subspecialties. Therefore, it is important that pregraduate medical education adequately covers the field of geriatric medicine. However, in most medical faculties in Europe today, learning objectives in geriatric medicine are often substandard or not even explicitly addressed. As a first step to encourage undergraduate teaching in geriatric medicine, the European Union of Medical Specialists -Geriatric Medicine Section (UEMS-GMS) recently developed a catalogue of learning goals using a modified Delphi technique in order to encourage education in this field. This catalogue of learning objectives for geriatric medicine focuses on the minimum requirements with specific learning goals in knowledge, skills and attitudes that medical students should have acquired by the end of their studies.In order to ease the implementation of this new, competence-based curriculum among the medical faculties in universities teaching in the German language, the authors translated the published English language curriculum into German and adapted it according to medical language and terms used at German-speaking medical faculties and universities of Austria, Germany and Switzerland. This article contains the final German translation of the curriculum. The Geriatric Medicine Societies of Germany, Austria, and Switzerland formally endorse the present curriculum and recommend that medical faculties adapt their curricula for undergraduate teaching based on this catalogue.

Long-term quality of life of liver transplant recipients beyond 60 years of age

Due to ameliorated surgery as well as better immunosuppression, the recipient age after liver transplantation has been extended over the past years. This study aimed to investigate the health related quality of life after liver transplantation in recipients beyond 60 years of age. The SF-36 was used to evaluate the recipients' health-related quality of life as standardized tool. It comprises 36 items that are attributed to 8 subscales attributed to 2 components: the physical component score and the mental component score. Differences in the health-related quality of life between the included aged recipients and age-matched general population as well as among female and male recipients. Aged recipients showed significantly lower scores in physical functioning (29 vs. 76, p = 0.001), role physical (42 vs. 73, p = 0.003), bodily pain (34 vs. 71, p = 0.003), general health (28 vs. 59, p = 0.001), vitality (25 vs. 61, p = 0.001), social functioning (36 vs. 87, p =0.001), role emotional (46 vs. 89, p = 0.001) as well as the physical component score (28 vs. 76, p = 0.001). Aged female recipients showed lower results as compared to males in social functioning, physical functioning, role physical, and social functioning (p = 0.03 respectively) but comparable results in the remaining. Quality of life seems to be an issue among aged recipients and should be assessed on a regular basis.

Considerations for the development of an undergraduate curriculum in geriatric medicine

BACKGROUND

Although the number of older patients is increasing in almost all medical specialties, the interest of medical students in geriatrics as a career is still low. Because quality of medical education and educators strongly influences student career decisions, it is important to develop curricula that motivate students to become self-directed, lifelong learners in the field of geriatric medicine.

OBJECTIVES

We evaluated training aspects in terms of time, core content of teaching goals, and quality of undergraduate geriatric education in medical schools in Austria and Germany.

METHODS

A standardized paper questionnaire was sent to all 36 German and 4 Austrian medical faculties to evaluate quantitative aspects, content, and quality of pregraduate medical education in geriatrics. Results were compared to the recommendations of the Geriatric Medicine Section of the European Union of Medical Specialists (UEMS).

RESULTS

A total of 33/36 (92 of the German medical faculties) and 4/4 (100 of the Austrian medical faculties) responded to the questionnaire. In most of the faculties, geriatric medicine was taught as an independent discipline in the core curriculum, with learning objectives absent in almost one third of the faculties. A medical student's first contact with geriatric medicine occurred on average during the second clinical year (median 8th semester). Although the content of geriatric curricula strongly varied among the faculties, core knowledge as recommended by the UEMS was integrated into most of the curricula. Teaching strategies regarding the development of attitudes and skills also recommended by the UEMS were identified in the curriculum of only some faculties.

CONCLUSIONS

Geriatrics seems to be an established subject in most German and Austrian faculties. However, the current data clearly indicate highly variable quality in geriatric pregraduate training at German and Austrian universities. Because curricula should prepare young people using competence-based training and assessment methods, room for improvement remains not only in terms of structure, but also regarding quality of training to develop self-directed lifelong learners.

Solid organ transplantation: technical progress meets human dignity: a review of the literature considering elderly patients' health related quality of life following transplantation

INTRODUCTION

Many transplant studies in elderly patients focus on survival and mortality rates. It was the aim of this review to evaluate publications dealing with individual patient performance and independence.

METHODS

The literature search included all articles retrievable for the hit "transplantation in elderly recipients" between 1960 and 2010. For quality search the inclusion criteria were as follows: older than 60 years and transplanted kidney, liver, heart, lung or pancreas from a deceased or living donor. We focussed on parameters concerning quality of life, frailty, nutritional status/weight loss, drugs/interactions/polypharmacy, gait/osteoporosis/fracture, delirium/dementia and geriatric assessment to address physical and psychosocial functionality of elderly recipients.

RESULTS

The initial hit list contained 1427 citations from electronic databases. 249 abstracts thereof were selected for full review. A total of 60 articles met final inclusion criteria. Finally, only five studies met the qualitative inclusion criteria as listed above.

CONCLUSION

The number of elderly patients placed on waiting lists has increased dramatically and will further grow. Interdisciplinary collaboration and distinct patient selection is recommended in most of the studies. However, data concerning quality of life and related parameters in elderly transplant recipients are rare.

Serum albumin, subjective global assessment, body mass index and the bioimpedance analysis in the assessment of malnutrition in patients up to 15 years after liver transplantation

BACKGROUND

The subjective global assessment (SGA) or the body mass index (BMI) is used to determine the nutritional state after LTX. Bioelectrical impedance analysis (BIA) is used as tool to determine body composition by nutritional care professionals.

METHODS

BIA, SGA, BMI, and serum albumin (SA) levels were performed to assess malnutrition following liver transplantation. BIA measurement was used as reference standard to determine existing malnutrition. A phase angle (PA) <5 was used to define potentially existing chronic disease-related malnutrition as a standard. All other measured parameters were compared with respect to their prognostic accuracy regarding the prediction of malnutrition as compared to the mentioned standard.

RESULTS

Seventy-one recipients (51 men, 20 women) were included. Median age was 58, weight 77 kg, BMI 26 kg/m(2) , PA 4.1°, and SA 4.3 g/dL. According to the Nutritional Risk Screening 2002, 9.4% (6/71), to BMI 15.4% (11/71), to SA 30.9% (22/71), and to BIA 36.5% (28/71) of the patients were malnourished. PA did not correlate with BMI or NA, there was a significant correlation with SA (p = 0.001). Univariate analysis revealed SA as independent predictor for malnutrition. ROC analysis for all parameters revealed a significantly (p < 0.05) better area under the receiver operating characteristic curve for SA (0.812) than for BMI (0.603) for the prediction of malnutrition.

CONCLUSION

SGA or BMI calculation alone does not suffice to evaluate the nutritional status. SA seems to play a crucial role in the prediction of severe disease-related malnutrition in this special patient cohort.

[Cerebrovascular disease]

The present article presents correlations of frailty associated functional changes in older patients with the development and progression of cerebrovascular disease (CVD). Special focus is drawn on the impact of well established risk factors for the development of CVD such as diabetes, hypertension and smoking on frailty markers especially in the light of functional recovery following an acute cerebrovascular event.

Gamma-hydroxybutyric acid in the treatment of alcohol withdrawal syndrome in patients admitted to hospital

Gamma-hydroxybutyric acid is a gamma-aminobutyric acid analogue which can be found in the human brain and is believed to be a neurotransmitter in the central nervous system. In animal experiments as well as in humans gamma-hydroxybutyric acid has been shown to alleviate the symptoms of the alcohol withdrawal syndrome. 299 patients, who were admitted to hospital for reasons primarily unrelated to their alcohol dependence, were treated with gamma-hydroxybutyric acid when symptoms of the alcohol withdrawal syndrome occurred. Gamma-hydroxybutyric acid was usually given at a daily dose of 50 mg/kg in 3 divided doses, the clinical course of the patients was followed for 7 days or until discharge from hospital. Patients were 214 men and 82 women aged 18-87 years. The reasons for admission to hospital were frequently internal diseases, neurological/psychiatric problems, trauma or surgery. At the start of gamma-hydroxybutyric acid treatment, tremor was present in 81% of patients, sweating in 76% and unrest in 92%. Symptoms occurred 1-72 hours after admission. The efficacy of gamma-hydroxybutyric acid to ameliorate or suppress the symptoms of the alcohol withdrawal syndrome was judged to be excellent in 57%, good in 34%, fair in 18%, insufficient in 3% of patients. Drug tolerance was judged to be excellent in 79%, good in 17%, fair in 2% and poor only in 1% of patients. Adverse events were rare and mild. It is concluded that gamma-hydroxybutyric acid is an attractive alternative to tranquilizers in the management of the alcohol withdrawal syndrome in hospital.

Predicting the risk of restenosis after angioplasty in patients with peripheral arterial disease

Restenosis is a serious therapeutic problem after percutaneous transluminal angioplasty (PTA). Strategies for the prevention of late restenosis include the use of antiaggregatory and anticoagulant drugs, aggressive lipid-lowering, intravascular radiation and others. As some of these therapeutic options are not without side effects it is important to identify patients with an increased risk to develop restenosis. Major clinically recognizable risk factors for restenosis are advanced disease stage and female gender. Elevated plasma levels of fibrinogen, Lp(a), CRP, and migration-inducing activity appear to indicate an unfavorable clinical outcome, and so does post-interventional increase of vWF and PAI-1 antigen. For peripheral arterial disease, only one study has addressed the influence of homocysteine levels upon the restenosis rate after PTA. Although homocysteine levels were elevated in >50% of patients at entry, they were not associated with a higher restenosis rate. Currently the available data allow a rough approximation of a patient's individual risk.

Silent haemoglobin variants and determination of HbA(1c) with the HPLC Bio-Rad Variant II

AIMS

To evaluate the determination of HbA(1c) with an automated high performance liquid chromatography (HPLC) method in patients with clinically silent haemoglobin variants.

METHODS

HbA(1c) values were determined with the ion exchange HPL Bio-Rad Variant II using the high resolution beta thalassaemia programme in patients with silent haemoglobin variants, namely: Hb Graz, Hb Sherwood Forest, Hb O Padova, and Hb D.

RESULTS

All of these haemoglobin variants caused additional peaks in the chromatograms. No clinically useful HbA(1c) results were produced for patients with Hb Graz and Hb Sherwood Forest, the results for the patient with Hb D were too low, but the results for patients with Hb O Padova were acceptable.

CONCLUSIONS

The development of this automated HPLC method modification with high resolution mode aids the identification of interference caused by the described clinically silent haemoglobin variants in HbA(1c) determination.

Effect of aspirin treatment in patients with peripheral arterial disease monitored with the platelet function analyzer PFA-100

We have used the platelet analyzer PFA-100TM to assess the effect of aspirin (ASA) in patients with documented peripheral arterial disease (PAD). Thirty-one previously untreated patients were recruited. Laboratory investigations, including the collagen and adenosine diphosphate closure time (CADP-CT) and the collagen and epinephrine closure time (CEPI-CT) were performed before and 7 days after treatment with 100 mg ASA per day. Five patients were excluded from the final analysis: one patient did not appear for second examination, in one patient type I von Willebrand disease was diagnosed, and three patients with prolonged CEPI-CT admitted the intake of non-steroidal anti-inflammatory drugs. Prior to ASA treatment, CADP-CT was 90 +/- 15 s (range, 67-124 s) and CEPI-CT was 116 +/- 27 s (range, 78-164 s). There was a significant negative correlation between CADP-CT and von Willebrand factor antigen (r = -0.57, P = 0.001). After treatment with 100 mg ASA per day, CADP-CT was not significantly different (96 +/- 22 s; range, 65-158 s). CEPI-CT, however, was prolonged in all patients, compared with pre-ASA values (226 +/- 82 s; range, 89 to > 300 s). In 12 of 26 patients, CEPI-CT was > 300 s and in another four of 26 patients CEPI-CT was prolonged to more than the upper normal range ('responders'). In the remaining 10 patients, CEPI-CT values did not exceed the upper limit of the normal range ('non-responders'). Five non-responders were re-investigated after intake of 300 mg ASA per day for 3 weeks; in none of these was a CEPI-CT > 165 s recorded. We conclude that 40% of PAD patients have an inadequate response to ASA, as determined by the PFA-100TM CEPI-CT. Whether these patients have a reduced benefit from this treatment remains to be investigated.

[Determination of glycated hemoglobins (Hb A1c)]

Glycated hemoglobin is measured as HbA1c and is the result of an irreversible non-enzymatic glycation of the beta chain of hemoglobin A. HbA1c is used routinely to assess long term glycemic control in patients with diabetes mellitus. There are more than 20 determination methods, the techniques used are cation-exchange chromatography, electrophoresis, affinity chromatography and immunoassays, although each of these techniques measures a different fraction of the glycated hemoglobin. In addition, genetic hemoglobin variants and chemically modified derivates of hemoglobin can affect the HbA1c measurement and thus can not be included in international attempts for standardization. This manuscript reviews the current information on glycation of hemoglobin, HbA1c determination methods, interferences and attempts for standardization. We aim at pointing out to the reader the current problems of glycated hemoglobin determination and to describe the necessary measures which need to be taken for proper measurement of HbA1c.

Thromboprophylaxis with 60 mg enoxaparin is safe in hip trauma surgery

BACKGROUND

Little information is available concerning dosage and optimal initiation of thromboprophylactic therapy with low-molecular-weight heparin (enoxaparin) in nonelective hip surgery. The aim of our prospective study was to evaluate the incidence of clinically apparent deep vein thrombosis (DVT), pulmonary embolism (PE), and major hemorrhage in patients receiving thromboprophylaxis with enoxaparin undergoing hip surgery after hip fracture.

METHOD

From 946 consecutive patients admitted with hip fractures, 897 were operated on and received enoxaparin according to the following regimen: Preoperative heparinization from time of admission onwards. Administration of 60 mg enoxaparin, in two doses (20 and 40 mg subcutaneously), during the first 5 days postoperatively. Prophylaxis for a minimum of 5 weeks (40 mg daily).

RESULTS

Clinical signs of DVT were present in 37 patients (4.2%), who all underwent venography. In five patients, DVT was confirmed (0.6%). None of these patients suffered from PE. Another four patients (0.4%) developed clinical signs of PE, and suspected diagnosis was confirmed by computed tomographic scan in two (0.2%). No deaths because of PE were observed. Major hemorrhage occurred in 42 patients (4.7%), there was one death from hemorrhage caused by an intracerebral event. No case of heparin-induced thrombocytopenia type II was observed.

CONCLUSION

Thromboprophylaxis with 60 mg enoxaparin daily, in split doses, starting before surgery, is safe and appropriate in patients with hip fractures. Clinically apparent DVT and PE are rarely observed, and bleeding complications are comparable to those occurring with a conventional thromboprophylactic regimen.

Oxidative stress during peripheral angioplasty. Implication for late restenosis?

BACKGROUND

Percutaneous transluminal angioplasty (PTA) is routine treatment for patients with peripheral arterial disease (PAD). The procedure induces local generation of reactive oxygen species (ROS), such as H2O2. Since these have been shown to stimulate vascular smooth muscle cell growth (VSMCG), we investigated peroxide levels in patients with PAD during PTA and related these results to late clinical outcome.

METHODS

Thirty patients (17 male, 13 female, 20 Fontain stage II, 10 Fontaine stage IV, median age 68 years) undergoing PTA of a 2-6 cm stenosis of the femoral or popliteal artery were included. The procedure was performed successfully in all patients. At follow-up six months thereafter restenosis was evaluated by duplex sonography. Total peroxide concentrations were determined in plasma drawn before, 6, 24 and 48 hours after the procedure by the Operoxide activityO assay, which is based on the reaction of horseradish peroxidase with plasma peroxides, using tetramethylbenzidine as the chromogenic substrate.

RESULTS

The median peroxide level before angioplasty was 280 mmol/L (range 47-549). Levels were higher in patients with advanced disease, in smokers and in patients with diabetes. In response to angioplasty, peroxide levels increased within 48 hours (p<0.001). Six months after the procedure, restenosis was observed in 10/30 (33 percent) of patients. Clinical outcome was not dependent upon baseline or postinterventional peroxide levels.

CONCLUSIONS

Elevated peroxide levels are seen in patients with advanced arteriosclerotic disease and in those with diabetes, but are not predictive for late restenosis.

Hemoglobin variants and determination of glycated hemoglobin (HbA1c)

Measurement of glycated hemoglobin in diabetic patients is an established procedure for evaluating long-term control of diabetes. The Diabetes Control and Complications Trial (DCCT), as well as the United Kingdom Prospective Diabetes Study (UKPDS), confirmed the direct relationship between the degree of glycemic control as estimated by glycohemoglobin (GHb) determinations and the development and progression of long-term complications in diabetic patients. Samples with known interferences of HbA(1c) determination as hemoglobinopathies are specifically excluded from certification testing and there are no guidelines or requirements for comparability of samples containing hemoglobin (Hb) variants. This paper reviews the interference of Hb variants on determination methods of glycated hemoglobin as they result in false HbA(1c) results.

Smooth muscle cell migration promoting activity of plasma predicts restenosis in patients with peripheral arterial occlusive disease undergoing angioplasty

BACKGROUND

Efficacy of percutaneous transluminal angioplasty (PTA) is limited by restenosis occurring in a large proportion of patients. Smooth muscle cell (SMC) migration is a major pathomechanism of restenosis. We studied SMC migration inducing activity of plasma from patients with peripheral arterial occlusive disease (PAOD) undergoing PTA.

METHODS AND RESULTS

SMC migration was determined in a two-dimensional assay system after addition of 1/25 plasma dilutions. Mean increase in migration area was 65.5 +/- 33.8% in normal controls and 67.7 +/- 53.2% in patients with PAOD. 6 hours after PTA, plasmatic migration inducing activity was largely unchanged. In 19/30 patients with restenosis (6 months after PTA) migration promoting activity (82.7 +/- 60.0) was significantly higher than in 11/30 patients with patent vessels (41.8 +/- 21.0; p = 0.03). No correlation of clinical risk factors with outcome was observed. A weak correlation was found between plasmatic migration promoting activity and levels of epidermal growth factor and transforming growth factor-beta.

CONCLUSION

The capacity of human plasma to stimulate SMC migration in tissue culture can be used to assess the risk for restenosis after PTA in patients with PAOD.

Changes in the fibrinolytic system in patients with peripheral arterial occlusive disease undergoing percutaneous transluminal angioplasty

We have investigated fibrinolytic parameters in 33 patients with peripheral arterial occlusive disease (PAOD) before and 6, 24, and 48 hours after percutaneous transluminal angioplasty (PTA) as well as in 35 gender-matched healthy controls, whose mean age was not significantly different from the mean age of the patients. PAOD patients had significantly higher plasma levels of t-PA antigen (12.0+/-4.9 vs. 9.2+/-5.5 ng/ml), PAI-1 antigen (34.8+/-22.1 vs. 27.2+/-23.6 ng/ml), PAI-1 activity (10.0+/-6.5 vs. 8.0+/-8.0 U/ml), PCI (188.2+/-55.6 vs. 134.1+/-75.5% as compared with normal human plasma), and fibrinogen (420.2+/-92.6 vs. 261.9+/-32.7 mg/dl) as compared with controls. After angioplasty, fibrinolytic parameters and fibrinogen levels increased, reaching higher than preintervention levels 24 and 48 hours after the intervention. Six months after initially successful PTA, restenosis was demonstrated in 14 out of 33 patients (42%). Patients with late restenosis had significantly higher levels of PAI-1 activity 24 and 48 hours after PTA, as compared with patients with late patency (24 hours: 16.1+/-8.0 vs. 10.0+/-7.4; 48 hours: 16.5+/-7.9 vs. 12.0+/-7.0; p<0.05 for both time points). The results suggest that impaired fibrinolysis early after PTA might be a cause or marker of a disturbed repair process of vascular injury, leading to restenosis.