Treatment of hypertension in patients 80 years of age or older

BACKGROUND

Whether the treatment of patients with hypertension who are 80 years of age or older is beneficial is unclear. It has been suggested that antihypertensive therapy may reduce the risk of stroke, despite possibly increasing the risk of death.

METHODS

We randomly assigned 3845 patients from Europe, China, Australasia, and Tunisia who were 80 years of age or older and had a sustained systolic blood pressure of 160 mm Hg or more to receive either the diuretic indapamide (sustained release, 1.5 mg) or matching placebo. The angiotensin-converting-enzyme inhibitor perindopril (2 or 4 mg), or matching placebo, was added if necessary to achieve the target blood pressure of 150/80 mm Hg. The primary end point was fatal or nonfatal stroke.

RESULTS

The active-treatment group (1933 patients) and the placebo group (1912 patients) were well matched (mean age, 83.6 years; mean blood pressure while sitting, 173.0/90.8 mm Hg); 11.8% had a history of cardiovascular disease. Median follow-up was 1.8 years. At 2 years, the mean blood pressure while sitting was 15.0/6.1 mm Hg lower in the active-treatment group than in the placebo group. In an intention-to-treat analysis, active treatment was associated with a 30% reduction in the rate of fatal or nonfatal stroke (95% confidence interval [CI], -1 to 51; P=0.06), a 39% reduction in the rate of death from stroke (95% CI, 1 to 62; P=0.05), a 21% reduction in the rate of death from any cause (95% CI, 4 to 35; P=0.02), a 23% reduction in the rate of death from cardiovascular causes (95% CI, -1 to 40; P=0.06), and a 64% reduction in the rate of heart failure (95% CI, 42 to 78; P<0.001). Fewer serious adverse events were reported in the active-treatment group (358, vs. 448 in the placebo group; P=0.001).

CONCLUSIONS

The results provide evidence that antihypertensive treatment with indapamide (sustained release), with or without perindopril, in persons 80 years of age or older is beneficial. (ClinicalTrials.gov number, NCT00122811 [ClinicalTrials.gov].).

Use of probiotic Lactobacillus preparation to prevent diarrhoea associated with antibiotics: randomised double blind placebo controlled trial

OBJECTIVE

To determine the efficacy of a probiotic drink containing Lactobacillus for the prevention of any diarrhoea associated with antibiotic use and that caused by Clostridium difficile.

DESIGN

Randomised double blind placebo controlled study.

PARTICIPANTS

135 hospital patients (mean age 74) taking antibiotics. Exclusions included diarrhoea on admission, bowel pathology that could result in diarrhoea, antibiotic use in the previous four weeks, severe illness, immunosuppression, bowel surgery, artificial heart valves, and history of rheumatic heart disease or infective endocarditis.

INTERVENTION

Consumption of a 100 g (97 ml) drink containing Lactobacillus casei, L bulgaricus, and Streptococcus thermophilus twice a day during a course of antibiotics and for one week after the course finished. The placebo group received a longlife sterile milkshake.

PRIMARY OUTCOME

occurrence of antibiotic associated diarrhoea. Secondary outcome: presence of C difficile toxin and diarrhoea.

RESULTS

7/57 (12%) of the probiotic group developed diarrhoea associated with antibiotic use compared with 19/56 (34%) in the placebo group (P=0.007). Logistic regression to control for other factors gave an odds ratio 0.25 (95% confidence interval 0.07 to 0.85) for use of the probiotic, with low albumin and sodium also increasing the risk of diarrhoea. The absolute risk reduction was 21.6% (6.6% to 36.6%), and the number needed to treat was 5 (3 to 15). No one in the probiotic group and 9/53 (17%) in the placebo group had diarrhoea caused by C difficile (P=0.001). The absolute risk reduction was 17% (7% to 27%), and the number needed to treat was 6 (4 to 14).

CONCLUSION

Consumption of a probiotic drink containing L casei, L bulgaricus, and S thermophilus can reduce the incidence of antibiotic associated diarrhoea and C difficile associated diarrhoea. This has the potential to decrease morbidity, healthcare costs, and mortality if used routinely in patients aged over 50.

TRIAL REGISTRATION

National Research Register N0016106821.

Probiotics in prevention of antibiotic associated diarrhoea: meta-analysis

OBJECTIVE

To evaluate efficacy of probiotics in prevention and treatment of diarrhoea associated with the use of antibiotics.

DESIGN

Meta-analysis; outcome data (proportion of patients not getting diarrhoea) were analysed, pooled, and compared to determine odds ratios in treated and control groups.

IDENTIFICATION

Studies identified by searching Medline between 1966 and 2000 and the Cochrane Library. Studies reviewed Nine randomised, double blind, placebo controlled trials of probiotics.

RESULTS

Two of the nine studies investigated the effects of probiotics in children. Four trials used a yeast (Saccharomyces boulardii), four used lactobacilli, and one used a strain of enterococcus that produced lactic acid. Three trials used a combination of probiotic strains of bacteria. In all nine trials, the probiotics were given in combination with antibiotics and the control groups received placebo and antibiotics. The odds ratio in favour of active treatment over placebo in preventing diarrhoea associated with antibiotics was 0.39 (95% confidence interval 0.25 to 0.62; P<0.001) for the yeast and 0.34 (0.19 to 0.61; P<0.01 for lactobacilli. The combined odds ratio was 0.37 (0.26 to 0.53; P<0.001) in favour of active treatment over placebo.

CONCLUSIONS

The meta-analysis suggests that probiotics can be used to prevent antibiotic associated diarrhoea and that S boulardii and lactobacilli have the potential to be used in this situation. The efficacy of probiotics in treating antibiotic associated diarrhoea remains to be proved. A further large trial in which probiotics are used as preventive agents should look at the costs of and need for routine use of these agents.

Development and validation of a score to assess risk of adverse drug reactions among in-hospital patients 65 years or older: the GerontoNet ADR risk score

BACKGROUND

The aim of the present study was to develop and validate a method of identifying elderly patients who are at increased risk for an adverse drug reaction (ADR).

METHODS

Data from the Gruppo Italiano di Farmacoepidemiologia nell'Anziano (Italian Group of Pharmacoepidemiology in the Elderly) were used to develop an ADR risk score. Variables associated with ADRs were identified by a stepwise logistic regression analysis and used to compute the ADR risk score. The ADR risk score was then validated in a sample of older adults who were admitted to 4 university hospitals in Europe (validation study).

RESULTS

Of 5936 patients (mean [SD] age, 78.0 [7.2] years) in the Gruppo Italiano di Farmacoepidemiologia nell'Anziano sample, 383 (6.5%) experienced an ADR. The number of drugs and a history of an ADR were the strongest predictors of ADRs, followed by heart failure, liver disease, presence of 4 or more conditions, and renal failure. These variables were used to compute the ADR risk score. The area under the receiver operator characteristic curve, which assesses the ability of the risk score to predict ADRs, was 0.71 (95% confidence interval, 0.68-0.73). Overall, 483 patients entered the validation study (mean [SD] age, 80.3 [7.6] years), and 56 (11.6%) experienced an ADR. The area under the receiver operator characteristic curve in this sample was 0.70 (95% confidence interval, 0.63-0.78).

CONCLUSIONS

This study proposes a practical and simple method of identifying patients who are at an increased risk of an ADR. This approach may be useful in clinical practice as a tool to identify patients at risk and in research to target a population that can benefit from interventions aimed to reduce drug-related illness.

Hormonal therapy increases arterial compliance in postmenopausal women

OBJECTIVES

This study investigated the effects of hormonal therapy on large arterial properties.

BACKGROUND

Arterial stiffness is an emerging risk marker for coronary heart disease and is potentially modifiable. Postmenopausal use of hormonal therapy is associated with a lower risk of coronary heart disease.

METHODS

Total systemic arterial compliance (SAC) and pulse wave velocity (PWV) were determined in 26 premenopausal and 52 postmenopausal women, 26 of whom were taking hormonal therapy.

RESULTS

Arterial compliance was greater in the premenopausal group (mean +/- SEM 0.57 +/- 0.04 arbitrary compliance units [ACU]) than in the postmenopausal group not taking hormonal therapy (0.26 +/- 0.02 ACU, p = 0.001). Postmenopausal women taking hormonal therapy had a significantly increased total SAC compared with women not taking hormonal therapy (0.43 +/- 0.02 vs. 0.26 +/- 0.02 ACU, p = 0.001). PWV in the aortofemoral region in the premenopausal women was 6.0 +/- 0.2 vs. 8.9 +/- 0.3 m/s (p < 0.001) in untreated postmenopausal women. However, postmenopausal women taking hormonal therapy had a significantly lower PWV than those not taking hormonal therapy (7.9 +/- 0.2 vs. 8.9 +/- 0.3 m/s, p = 0.01). Eleven postmenopausal women had their hormone replacement therapy withdrawn for 4 weeks, resulting in a significant decrease in SAC and a significant increase in aortofemoral PWV.

CONCLUSIONS

The increased SAC and decreased PWV in women receiving hormonal therapy suggest that such therapy may decrease stiffness of the aorta and large arteries in postmenopausal women, with potential benefit for age-related cardiovascular disorders. The reduction of arterial compliance with age appears to be altered with hormonal therapy.

Ageing and vascular ageing

There is an age related decline in various physiological processes. Vascular ageing is associated with changes in the mechanical and the structural properties of the vascular wall, which leads to the loss of arterial elasticity and reduced arterial compliance. Arterial compliance can be measured by different parameters like pulse wave velocity, augmentation index, and systemic arterial compliance. There is evidence that arterial compliance is reduced in disease states such as hypertension, diabetes, and end stage renal failure. Changes in arterial compliance can be present before the clinical manifestation of cardiovascular disease. Pharmacological and non-pharmacological measures have been shown to improve arterial compliance. Arterial compliance may constitute an early cardiovascular risk marker and may be useful in assessing the effects of drugs on the cardiovascular system. Pharmacogenetics and genetics of arterial compliance in the future will improve our knowledge and understanding about vascular ageing.

Serum calcification propensity predicts all-cause mortality in predialysis CKD

Medial arterial calcification is accelerated in patients with CKD and strongly associated with increased arterial rigidity and cardiovascular mortality. Recently, a novel in vitro blood test that provides an overall measure of calcification propensity by monitoring the maturation time (T50) of calciprotein particles in serum was described. We used this test to measure serum T50 in a prospective cohort of 184 patients with stages 3 and 4 CKD, with a median of 5.3 years of follow-up. At baseline, the major determinants of serum calcification propensity included higher serum phosphate, ionized calcium, increased bone osteoclastic activity, and lower free fetuin-A, plasma pyrophosphate, and albumin concentrations, which accounted for 49% of the variation in this parameter. Increased serum calcification propensity at baseline independently associated with aortic pulse wave velocity in the complete cohort and progressive aortic stiffening over 30 months in a subgroup of 93 patients. After adjustment for demographic, renal, cardiovascular, and biochemical covariates, including serum phosphate, risk of death among patients in the lowest T50 tertile was more than two times the risk among patients in the highest T50 tertile (adjusted hazard ratio, 2.2; 95% confidence interval, 1.1 to 5.4; P=0.04). This effect was lost, however, after additional adjustment for aortic stiffness, suggesting a shared causal pathway. Longitudinally, serum calcification propensity measurements remained temporally stable (intraclass correlation=0.81). These results suggest that serum T50 may be helpful as a biomarker in designing methods to improve defenses against vascular calcification.

Aortic stiffness is independently associated with rate of renal function decline in chronic kidney disease stages 3 and 4

Aortic stiffness and chronic kidney disease are closely linked by shared risk factors and associated increased cardiovascular mortality. At lower levels of renal function, aortic stiffness is independently associated with glomerular filtration rate. However, the longitudinal impact of aortic stiffness on renal function has not been reported previously. A cohort of 133 patients with chronic kidney disease stages 3 and 4 (estimated glomerular filtration rate: 15 to 59 mL/min per 1.73 m(2)) underwent prospective measurement of arterial stiffness parameters and monitoring of renal function. Aortic pulse wave velocity measurement was performed in 120 patients. The mean age was 69+/-12 years (mean+/-SD; 103 men, 30 women, and 23.3% diabetic). Mean systolic blood pressure was 155+/-21 mm Hg, and mean diastolic blood pressure was 83+/-11 mm Hg. The mean Modification of Diet in Renal Disease estimated glomerular filtration rate was 32+/-11 mL/min per 1.73 m(2). Change in renal function was measured using reciprocal creatinine plots and the dichotomous combined end point of > or = 25% decline in renal function or start of renal replacement therapy. After stepwise multivariate analysis, aortic pulse wave velocity was independently associated with gradient of reciprocal creatinine plot (r=0.46; P=0.014). In multivariate analysis of the end point of > or = 25% decline in renal function or start of renal replacement therapy, independent predictors were aortic pulse wave velocity (r=0.48; P=0.002), systolic blood pressure (r=0.17; P=0.039), and urine protein:creatinine ratio (r=0.20; P=0.021). We, therefore, conclude that aortic stiffening is independently associated with rate of change in renal function in patients with chronic kidney disease stages 3 and 4.

Phosphorylated fetuin-A-containing calciprotein particles are associated with aortic stiffness and a procalcific milieu in patients with pre-dialysis CKD

BACKGROUND

Vascular stiffening occurs in normal ageing and is accelerated in chronic kidney disease (CKD). Vascular calcification contributes to this stiffening and to the high incidence of vascular morbidity and mortality in this population. A network of inhibitors work in concert to reduce mineralization risk in extra-osseous tissue. Fetuin-A is an important systemic inhibitor of ectopic calcification. A fraction of the total circulating fetuin-A interacts with mineral ions to form stable colloidal complexes, calciprotein particles (CPP), preventing deposition. We sought to assess whether CPP fetuin-A levels were associated with procalcific factors and aortic stiffness in a cohort of patients with Stages 3 and 4 CKD.

METHODS

We measured fetuin-A CPP levels, serum inflammatory markers [C-reactive protein (CRP), interleukin-6, tumour necrosis factor-α], oxidized low-density lipoprotein (oxLDL), bone morphogenetic protein-2 (BMP-2) and -7 (BMP-7) and aortic pulse wave velocity (APWV) in a cohort of 200 CKD patients. Serum measurements were also made in 78 healthy controls. CPP fetuin-A phosphorylation was characterized by phosphate-affinity gel chromatography.

RESULTS

Fetuin-A-containing CPPs were only detectable in the serum of CKD patients. Inflammatory markers, oxLDL and BMP-2 levels were all significantly higher in the CKD than control subjects. CPP fetuin-A levels were independently associated with serum phosphate, high-sensitivity C-reactive protein, oxLDL, BMP-2/7 ratio and inversely with estimated glomerular filtration rate (model R(2) = 0.51). After adjusting for confounders, CPP fetuin-A levels were independently associated with APWV. Only phosphorylated fetuin-A was present in serum CPP.

CONCLUSION

Increased CPP fetuin-A levels reflect an increasingly procalcific milieu and are associated with increased aortic stiffness in patients with pre-dialysis CKD.

Testosterone suppression in men with prostate cancer leads to an increase in arterial stiffness and hyperinsulinaemia

The role of androgens in cardiovascular disease is uncertain. We aimed to determine the vascular effects of androgen suppression in men with prostate cancer. Arterial stiffness (or 'compliance') was measured in 16 men (71+/-9 years, mean+/-S.D.) prior to, and 3 months after, complete androgen suppression with gonadotrophin-releasing hormone analogues as treatment for prostate cancer. Fifteen control men (70+/-7 years) also had arterial stiffness studies at baseline and 3 months later. Two measures of arterial stiffness were employed: systemic arterial compliance (SAC) was measured by simultaneous recording of aortic flow and carotid artery pressure ('area method'), and pulse wave velocities (PWVs) were recorded with the 'Complior' system. The 16 cases underwent glucose-tolerance and fasting-lipids tests on both visits. After 3 months of testosterone suppression, there was a significant fall in SAC, which was not seen in the controls [mean change+/-S.E.M., -0.26+/-0.09 a.c.u. (arbitrary compliance unit) in the cases versus +0.06+/-0.11 in the controls; P =0.03). Central, but not peripheral, PWVs tended to increase in the cases (mean change+/-S.E.M. for aorto-femoral PWV, +0.5+/-0.4 m/s for cases versus -0.3+/-0.3 m/s for controls; P =0.08). After testosterone suppression, fasting insulin levels increased from 6.89+/-4.84 m-units/l to 11.34+/-8.16 m-units/l (mean+/-S.D.), total cholesterol increased from 5.32+/-0.77 mmol/l to 5.71+/-0.82 mmol/l and high-density lipoprotein cholesterol increased from 1.05+/-0.24 mmol/l to 1.26+/-0.36 mmol/l; P <0.005 for all. No significant change occurred in body-mass index, serum glucose, low-density lipoprotein cholesterol or triacylglycerol (triglyceride) levels. Our results indicate that loss of androgens in men leads to an increase in aortic stiffness and serum insulin levels, and may therefore adversely affect cardiovascular risk.

Is augmentation index a good measure of vascular stiffness in the elderly?

OBJECTIVES

we investigated the exact relationship between age and gender on augmentation pressure (AG) and augmentation index (AI) measured over the radial (muscular) and carotid (elastic) arteries.

DESIGN AND METHODS

AG is the contribution that wave reflection makes to systolic arterial pressure. AI is an indirect measure of arterial stiffness and is calculated as AG divided by pulse pressure (PP) x100. AG and AI both increase with age. AG and AI were measured in 458 subjects using SphygmoCor. A total of 755 readings were obtained (302 carotid, 453 radial). The mean age was 57.5 +/- 13.7 years. Diabetic subjects were excluded. Among the subjects, 13.5% were hypertensive.

RESULTS

statistically, women had mean values of AI significantly higher than men in both radial and carotid arteries. These differences were less marked with AG. Quadratic equations better described the relationship between AI and age but not AG and age. Thus, AI increased with age up to our median age of 55 years but plateaued thereafter, whereas the AG continued to increase steadily with age. A multiple regression analysis demonstrated that both AI and AG were negatively related to height and positively related to diastolic blood pressure (DBP).

CONCLUSIONS

AG continues to increase in the elderly over the age of 55, but not AI. AI is higher in women and higher when measured over the carotid than the radial. AI is positively related to DBP and negatively to height. AG is proposed as a more suitable measure of arterial stiffness than AI.

The aging of elastic and muscular arteries: a comparison of diabetic and nondiabetic subjects

OBJECTIVE

To compare age-related changes in the mechanical properties of different arterial segments in normal volunteers and subjects with type 2 diabetes.

RESEARCH DESIGN AND METHODS

In 169 subjects (diabetic n = 57 and nondiabetic n = 112), we assessed the mechanical properties of three arterial segments of differing wall composition. Pulse wave velocity (PWV) was measured noninvasively in a thoraco-abdominal segment (carotid femoral PWV [PWV(cf)]), in an upper limb muscular artery (carotid radial PWV [PWV(cr)]), and from the aorta to the finger (PWV from the aorta to the finger [PWV(fin)]). Central aortic compliance (CAC) was also measured.

RESULTS

Average CAC was lower (0.662 vs. 0.850, P < 0.05) and all measures of PWV tended to be faster in diabetic subjects despite the fact that they were, on average, 10 years younger. However, these measures were not related to age in diabetic subjects. After correcting for blood pressure, only PWV(cf) was associated with age in nondiabetic subjects (P < 0.001). Expressing results as ratios of nonelastic to elastic arterial segments (i.e., PWV(cr)-to-PWV(cf) and PWV(fin)-to-PWV(cf)) improved the relationship with age. Both PWV(cr)-to-PWV(cf) and PWV(fin)-to-PWV(cf) were significantly associated with age in nondiabetic subjects (r = -0.59, P < 0.001; r = -0.57, P < 0.001) but not in diabetic subjects (r = -0.15, P = 0.302; r = -0.24, P = 0.129). Multivariate analysis showed that the ratios were not associated with systolic blood pressure.

CONCLUSIONS

There are significant differences in the rate of age-related decline in vascular stiffness in elastic arteries of nondiabetic compared with diabetic arteries. Diabetic arteries appear to age at an accelerated rate at an earlier age and then reach a functional plateau.

Strategies to reduce the risk of iatrogenic illness in complex older adults

Older patients are particularly vulnerable to adverse drug reactions (ADRs) because age is associated with changes in pharmacokinetics and pharmacodynamics that may alter drug metabolism. In addition, other conditions, commonly observed in older adults, may increase the risk of ADRs in the older population (including polypharmacy, comorbidity, cognitive and functional limitations). ADRs in older adults are frequently preventable, suggesting that screening and prevention programmes aimed at reducing the rate of iatrogenic illness are necessary in this population. The present study reviews available approaches that may be used to screen and prevent the occurrence of ADRs in older adults, including medication review, avoiding the use of potentially inappropriate medications, computer-based prescribing systems and comprehensive geriatric assessment. Available evidence on these approaches is mixed and controversial, and none of them showed a clear beneficial effect on patients' health outcomes. Limitation of these interventions is the lack of standardisation, and these differences may give reason for the variability of the results documented in randomised clinical studies. Interestingly, most of the available research is focused on a single intervention targeting either clinical or pharmacological factors causing ADRs. When these approaches are combined, positive effects on patients health outcomes can be shown, suggesting that integration of skills from different health care professionals is needed to address medical complexity of the older adults. The challenge for future research is to integrate valuable information obtained by existing instruments and methodologies in a complete and global approach targeting all potential factors involved in the onset of ADRs.

Estimation of central aortic pressure by SphygmoCor requires intra-arterial peripheral pressures

Central arterial pressure, measured close to the heart, may be of more patho-physiological importance than conventional non-invasive cuff blood pressure. The technique of applanation tonometry using SphygmoCor has been proposed as a non-invasive method of estimating central pressure. This relies on mathematically derived generalized transfer functions, which have been previously validated using invasive peripheral pressure measurements. We compared simultaneous estimates of central aortic pressure using this technique with those measured directly during the routine diagnostic cardiac catheterization of 30 subjects (age range 27-84 years), half of whom were aged 65 years or more. This was done by applanating the left radial artery and recording the non-invasive brachial cuff blood pressure to generate a central aortic pressure estimate, using the SphygmoCor radial transfer function. The comparative results were analysed using Bland-Altman plots of mean difference. SphygmoCor, on average, underestimated systolic central arterial pressure by 13.3 mmHg and overestimated diastolic pressure by 11.5 mmHg. The results were similar in patients aged under and above 65 years. Furthermore, non-invasively measured brachial pressures were seen to give an overall closer estimate of the central arterial pressure than the SphygmoCor system. The transfer function has been validated from invasively measured arterial pressures and the current use by the system of non-invasive measures may explain the discrepancies. However, age, drugs and arterial disease would also be expected to play a role.

Polypharmacy in the Aging Patient: Management of Hypertension in Octogenarians

IMPORTANCE

Hypertension treatment is beneficial for most hypertensive patients. The benefits for patients who are very old and frail, especially those taking numerous medications, are less certain.

OBJECTIVE

To provide recommendations for the evaluation and treatment of hypertension among patients aged 80 years and older.

EVIDENCE ACQUISITION

MEDLINE, PubMed Central, and the Cochrane Database of Systematic Reviews were searched from inception through April 2015, with an emphasis on 2010-2015. Manual cross-referencing of review articles and meta-analyses was also performed to identify randomized controlled trials (RCTs) examining antihypertensive use in octogenarians. The search strategy included the following Medical Subject Headings: hypertension or high blood pressure and trials and oldest old or very old or very elderly.

FINDINGS

Six post hoc analyses of the previously published Hypertension in the Very Elderly Trial (HYVET) met the inclusion criteria. In the only placebo-controlled RCT on hypertension management in patients older than 80 years (HYVET; N = 3845), the treatment was associated with lower total mortality and key cardiovascular end points but the effect on stroke (fatal and nonfatal), which was the primary outcome, failed to reach the significance level (P = .06). Post hoc analyses of HYVET suggested that active hypertension treatment in very elderly patients was beneficial by reducing blood pressure in individuals with white coat hypertension, showed moderate benefits of the active treatment for cognition, a possible effect for fractures prevention, and sustained differences in reductions of total mortality and cardiovascular mortality in those receiving active treatment. However, patients were community dwelling and less disabled than individuals of the same age in general.

CONCLUSIONS AND RELEVANCE

Hypertensive patients who are healthy, functionally independent, and aged 80 years and older should be treated according to current recommendations for people older than 65 years. There is insufficient evidence regarding the benefits of hypertension treatment for frail polymedicated octogenarians, for whom treatment should be individualized.

Incidence and cost of medication harm in older adults following hospital discharge: a multicentre prospective study in the UK

Aims

Polypharmacy is increasingly common in older adults, placing them at risk of medication‐related harm (MRH). Patients are particularly vulnerable to problems with their medications in the period following hospital discharge due to medication changes and poor information transfer between hospital and primary care. The aim of the present study was to investigate the incidence, severity, preventability and cost of MRH in older adults in England postdischarge.

Methods

An observational, multicentre, prospective cohort study recruited 1280 older adults (median age 82 years) from five teaching hospitals in Southern England, UK. Participants were followed up for 8 weeks by senior pharmacists, using three data sources (hospital readmission review, participant telephone interview and primary care records), to identify MRH and associated health service utilization.

Results

Overall, 413 participants (37%) experienced MRH (556 MRH events per 1000 discharges), of which 336 (81%) cases were serious and 214 (52%) potentially preventable. Four participants experienced fatal MRH. The most common MRH events were gastrointestinal (n = 158, 25%) or neurological (n = 111, 18%). The medicine classes associated with the highest risk of MRH were opiates, antibiotics and benzodiazepines. A total of 328 (79%) participants with MRH sought healthcare over the 8‐week follow‐up. The incidence of MRH‐associated hospital readmission was 78 per 1000 discharges. Postdischarge MRH in older adults is estimated to cost the National Health Service £396 million annually, of which £243 million is potentially preventable.

Conclusions

MRH is common in older adults following hospital discharge, and results in substantial use of healthcare resources.

Association of polypharmacy and hyperpolypharmacy with frailty states: a systematic review and meta-analysis

PURPOSE

To investigate: (1) the cross-sectional association between polypharmacy, hyperpolypharmacy and presence of prefrailty or frailty; (2) the risk of incident prefrailty or frailty in persons with polypharmacy, and vice versa.

METHODS

A systematic review and meta-analysis was performed according to PRISMA guidelines. We searched PubMed, Web of Science, and Embase from 01/01/1998 to 5/2/2018. Pooled estimates were obtained through random effect models and Mantel-Haenszel weighting. Homogeneity was assessed with the I² statistic and publication bias with Egger's and Begg's tests.

RESULTS

Thirty-seven studies were included. The pooled proportion of polypharmacy in persons with prefrailty and frailty was 47% (95% CI 33-61) and 59% (95% CI 42-76), respectively. Increased odds ratio of polypharmacy were seen for prefrail (pooled OR = 1.52; 95% CI 1.32-1.79) and frail persons (pooled OR = 2.62, 95% CI 1.81-3.79). Hyperpolypharmacy was also increased in prefrail (OR = 1.95; 95% CI 1.41-2.70) and frail (OR = 6.57; 95% CI 9.57-10.48) persons compared to robust persons. Only seven longitudinal studies reported data on the risk of either incident prefrailty or frailty in persons with baseline polypharmacy. A significant higher odds of developing prefrailty was found in robust persons with polypharmacy (pooled OR = 1.30; 95% CI 1.12-1.51). We found no papers investigating polypharmacy incidence in persons with prefrailty/frailty.

CONCLUSIONS

Polypharmacy is common in prefrail and frail persons, and these individuals are also more likely to be on extreme drug regimens, i.e. hyperpolypharmacy, than robust older persons. More research is needed to investigate the causal relationship between polypharmacy and frailty syndromes, thereby identifying ways to jointly reduce drug burden and prefrailty/frailty in these individuals.

PROSPERO REGISTRATION NUMBER

CRD42018104756.

Ethnic differences in vascular stiffness and relations to hypertensive target organ damage

OBJECTIVE

People of Black African descent have greater risks of hypertensive target organ damage than would be anticipated for given levels of blood pressure. Arterial stiffness may further account for ethnic differences in risk.

DESIGN

Cross-sectional study.

SETTING

Population based, London, UK.

PARTICIPANTS

One hundred and three Europeans and 99 African Caribbeans aged 40-64 years.

METHODS

We measured resting and ambulatory blood pressure, and pulse wave velocity (PWV) of elastic and muscular arteries. Echocardiography measured interventricular septal thickness (IVST).

MAIN OUTCOME MEASURES

PWV, IVST.

RESULTS

Carotid-femoral PWV was 12.7 m/s [95% confidence interval (CI) 12.3, 13.1] in African Caribbeans and 11.2 m/s (10.9, 11.6) in Europeans (P < 0.0001). This difference persisted on adjustment for resting and ambulatory blood pressure, 12.4 versus 11.5 m/s (P = 0.003). The greater IVST in African Caribbeans (9.6 mm) compared to Europeans (9.1 mm, P = 0.0005), could only in part be accounted for by differences in carotid*femoral PWV. Stiffness in the muscular carotid-radial segment did not differ by ethnicity, but was positively associated with systolic pressure in Europeans (beta regression coefficient 0.033, P = 0.04), and negatively associated in African Caribbeans (-0.036, P = 0.04, and P = 0.02 for interaction).

CONCLUSIONS

Aortic stiffness is increased in African Caribbeans compared to Europeans, even when higher blood pressures are accounted for. It is most closely related to IVST, but contributes little to explaining ethnic differences. Stiffness of the upper limb muscular arteries did not differ by ethnicity, but remained favourable in the presence of hypertension in African Caribbeans, while being increased in Europeans. We suggest that this is due to ethnic differences in vascular remodelling.

Withdrawal of hormonal therapy for 4 weeks decreases arterial compliance in postmenopausal women

BACKGROUND

We demonstrated in a previous cross-sectional study that arterial compliance is elevated in postmenopausal women taking estrogen-containing hormonal therapy, which may partially account for the reduction in cardiovascular risk observed.

OBJECTIVE

To investigate the effects of withdrawal and recommencement of hormonal therapy, each for 4 weeks, on arterial compliance.

METHODS

Seventeen postmenopausal women [aged 56 +/- 4 years (mean +/- SD)] taking long-term hormonal therapy (+HT group) were studied at baseline, 4 weeks after withdrawal of hormonal therapy and again 4 weeks after recommencement. Systemic arterial compliance (SAC), pulse wave velocity (PWV) in the aorto-femoral and femoral-dorsalis pedis regions, and hemodynamic variables were measured at baseline, and at the end of each study intervention. As a time-control, seventeen postmenopausal women (aged 63 +/- 7 years) not taking hormonal therapy (-HT group) were also investigated.

RESULTS

SAC significantly decreased from 0.47 +/- 0.06 to 0.40 +/- 0.05 arbitrary compliance units (mean +/- SEM; P < 0.05) after 4 weeks withdrawal from hormonal therapy. PWV in the femoral-dorsalis pedis region was elevated significantly by the withdrawal of hormonal therapy (8.4 +/- 0.4 to 9.4 +/- 0.5 m/s; P < 0.05), but PWV in the aortofemoral region did not change. After therapy had been recommenced for 4 weeks, SAC and PWV in the femoral-dorsalis pedis region were restored to baseline values. The -HT group showed no difference in SAC or PWV, and mean arterial pressure did not change in either group throughout the study period.

CONCLUSION

These data suggest that hormonal modulation of distal arterial vascular tone may account for short-term changes in arterial compliance associated with estrogen-containing hormonal therapy.

Development and validation of a risk model for predicting adverse drug reactions in older people during hospital stay: Brighton Adverse Drug Reactions Risk (BADRI) model

Background

Older patients are at an increased risk of developing adverse drug reactions (ADR). Of particular concern are the oldest old, which constitute an increasingly growing population. Having a validated clinical tool to identify those older patients at risk of developing an ADR during hospital stay would enable healthcare staff to put measures in place to reduce the risk of such an event developing. The current study aimed to (1) develop and (2) validate an ADR risk prediction model.

Methods

We used a combination of univariate analysis and multivariate binary logistic regression to identify clinical risk factors for developing an ADR in a population of older people from a UK teaching hospital. The final ADR risk model was then validated in a European population (European dataset).

Results

Six-hundred-ninety patients (median age 85 years) were enrolled in the development stage of the study. Ninety-five reports of ADR were confirmed by independent review in these patients. Five clinical variables were identified through multivariate analysis and included in our final model; each variable was attributed a score of 1. Internal validation produced an AUROC of 0.74, a sensitivity of 80%, and specificity of 55%. During the external validation stage the AUROC was 0.73, with sensitivity and specificity values of 84% and 43% respectively.

Conclusions

We have developed and successfully validated a simple model to use ADR risk score in a population of patients with a median age of 85, i.e. the oldest old. The model is based on 5 clinical variables (≥8 drugs, hyperlipidaemia, raised white cell count, use of anti-diabetic agents, length of stay ≥12 days), some of which have not been previously reported.

Drug cessation in complex older adults: time for action

BACKGROUND

general opinion is growing that drug cessation in complex older patients is warranted in certain situations. From a clinical viewpoint, drug cessation seems most warranted in four situations, i.e., falls, delirium, cognitive impairment and end-of-life situations. To date, little information about the effects of drug cessation in these four situations is available.

OBJECTIVES

to identify the effects and effectiveness of drug cessation on falls, delirium and cognitive impairment. For end-of-life situations, we reviewed cessation of inappropriate drug use.

METHODS

electronic databases were searched using MeSH terms and relevant keywords. Studies published in English were included if they evaluated the effects of drug cessation in older persons, aged ≥65 years, with falls, delirium or cognitive impairment; or cessation of inappropriate drug use in end-of-life situations.

RESULTS

we selected seven articles for falls, none for delirium, two for cognition and two for end-of-life situations. Withdrawal of psychotropics reduced fall rate; a prescribing modification programme for primary care physicians reduced fall risk. Withdrawal of psychotropics and a systematic reduction of polypharmacy resulted in an improvement of cognition. Very little rigorous research has been conducted on reducing inappropriate medications in patients approaching end of life.

CONCLUSION

little research has focussed on drug cessation. Available studies showed a beneficial impact of cessation of psychotropic drugs on falls and cognitive status. More research in this field is needed. The issue of systematic drug withdrawal in end-of-life cases is controversial, but is increasingly relevant in the face of rising numbers of older people of this clinical status.

Elastin degradation is associated with progressive aortic stiffening and all-cause mortality in predialysis chronic kidney disease

In the large conduit arteries, elastin is important in maintaining vascular compliance. Studies in animal models suggest that elastin degradation may promote arteriosclerotic vascular changes. There is already a well-established link between aortic stiffening and mortality in the general population and in patients undergoing dialysis. Elastin degradation is mediated by several proteases, including matrix metalloproteinase 2 and cathepsin S. Elastin turnover may be inferred by measuring serum levels of elastin-derived peptides. We analyzed the serum concentration of these biomarkers, their endogenous inhibitors, and aortic pulse wave velocity in 200 patients with stages 3 and 4 chronic kidney disease and then serially in a subgroup of 65 patients over 36 months. Serum matrix metalloproteinase 2, cathepsin S, and elastin-derived peptide levels were independently associated with baseline aortic pulse wave velocity and changes in stiffness over the follow-up period. Higher matrix metalloproteinase 2 and elastin-derived peptide levels were also independently associated with preexisting cardiovascular disease. In multivariable Cox regression, higher serum elastin-derived peptide levels were independently associated with increased all-cause mortality (hazard ratio per SD increase=1.78; P=0.021). In predialysis chronic kidney disease, elastin degradation is an important determinant of arterial stiffness and is associated with all-cause mortality.

Does white coat hypertension require treatment over age 80?: Results of the hypertension in the very elderly trial ambulatory blood pressure side project

White coat hypertension is considered to be a benign condition that does not require antihypertensive treatment. Ambulatory blood pressure (ABP) was measured in 284 participants in the Hypertension in the Very Elderly Trial (HYVET), a double-blind randomized trial of indapamide sustained release 1.5 mg±perindopril 2 to 4 mg versus matching placebo in hypertensive subjects (systolic blood pressure 160-199 mm Hg) aged >80 years. ABP recordings (Diasys Integra II) were obtained in 112 participants at baseline and 186 after an average follow-up of 13 months. At baseline, clinic blood pressure (CBP) exceeded the morning ABP by 32/10 mm Hg. Fifty percent of participants fulfilled the established criteria for white coat hypertension. The highest ABP readings were in the morning (average 140/80 mm Hg), the average night-time pressure was low at 124/72 mm Hg, and the average 24-hour blood pressure was 133/77 mm Hg. During follow-up, the systolic/diastolic blood pressure placebo-active differences averaged 6/5 mm Hg for morning ABP, 8/5 mm Hg for 24-hour ABP, and 13/5 mm Hg for CBP. The lowering of blood pressure over 24 hours supports the reduction in blood pressure with indapamide sustained release±perindopril as the explanation for the reduction in total mortality and cardiovascular events observed in the main HYVET study. Because we estimate that 50% had white coat hypertension in the main study, this condition may benefit from treatment in the very elderly.

The Relationship Between Androgens and Arterial Stiffness in Older Men

OBJECTIVES

To assess the relationship between endogenous androgen levels and arterial stiffness in older men.

DESIGN

A retrospective, cross-sectional study.

SETTING

A London hospital-based, clinical research unit for the elderly.

PARTICIPANTS

Fifty-five men (mean age+/-standard deviation=71.1+/-8.0).

INTERVENTION

Sex hormone-binding globulin (SHBG), testosterone, and dehydroepiandrosterone sulfate (DHEAS) were measured in all subjects who had a stored serum sample drawn the same day as arterial stiffness measures were performed. Free testosterone index (FTI) was calculated ((total testosterone/SHBG) x 100 (%)). The measures of arterial stiffness used were pulse wave velocity (PWV) using the Complior system and systemic arterial compliance (SAC) using the area method.

MEASUREMENTS

Relationship between arterial stiffness and serum androgens.

RESULTS

: FTI showed a strong positive relationship with SAC (r=0.507, P<.001) and, correspondingly, an inverse relationship with carotid-femoral (C-F) and carotid-radial (C-R) PWV (r=-0.427 and -0.402, respectively, P<or=.002). With multiple regression, including age, blood pressure, cholesterol, body mass index, and waist/hip ratio, FTI remained a significant determinant of SAC and C-R PWV but not C-F PWV. In the subgroup of men without cardiovascular disease or vasoactive medication use (n=37), all three relationships remained significant. DHEAS was inversely related to C-F PWV only (r=-0.304, P=.041).

CONCLUSION

The known association between lower androgenicity and increased cardiovascular risk in men might be explained by altered vascular stiffness.