Validation of the ADFICE_IT Models for Predicting Falls and Recurrent Falls in Geriatric Outpatients

OBJECTIVES

Before being used in clinical practice, a prediction model should be tested in patients whose data were not used in model development. Previously, we developed the ADFICE_IT models for predicting any fall and recurrent falls, referred as Any_fall and Recur_fall. In this study, we externally validated the models and compared their clinical value to a practical screening strategy where patients are screened for falls history alone.

DESIGN

Retrospective, combined analysis of 2 prospective cohorts.

SETTING AND PARTICIPANTS

Data were included of 1125 patients (aged ≥65 years) who visited the geriatrics department or the emergency department.

METHODS

We evaluated the models' discrimination using the C-statistic. Models were updated using logistic regression if calibration intercept or slope values deviated significantly from their ideal values. Decision curve analysis was applied to compare the models' clinical value (ie, net benefit) against that of falls history for different decision thresholds.

RESULTS

During the 1-year follow-up, 428 participants (42.7%) endured 1 or more falls, and 224 participants (23.1%) endured a recurrent fall (≥2 falls). C-statistic values were 0.66 (95% CI 0.63-0.69) and 0.69 (95% CI 0.65-0.72) for the Any_fall and Recur_fall models, respectively. Any_fall overestimated the fall risk and we therefore updated only its intercept whereas Recur_fall showed good calibration and required no update. Compared with falls history, Any_fall and Recur_fall showed greater net benefit for decision thresholds of 35% to 60% and 15% to 45%, respectively.

CONCLUSIONS AND IMPLICATIONS

The models performed similarly in this data set of geriatric outpatients as in the development sample. This suggests that fall-risk assessment tools that were developed in community-dwelling older adults may perform well in geriatric outpatients. We found that in geriatric outpatients the models have greater clinical value across a wide range of decision thresholds compared with screening for falls history alone.

Monitoring the Well-being of Older People by Energy Usage Patterns: Systematic Review of the Literature and Evidence Synthesis

BACKGROUND

Due to the aging population, there is a need for monitoring well-being and safety while living independently. A low-intrusive monitoring system is based on a person's use of energy or water.

OBJECTIVE

The study's objective was to provide a systematic overview of studies that monitor the health and well-being of older people using energy (eg, electricity and gas) and water usage data and study the outcomes on health and well-being.

METHODS

CENTRAL, Embase, MEDLINE (Ovid), Scopus, Web of Science, and Google Scholar were searched systematically from inception until November 8, 2021. The inclusion criteria were that the study had to be published in English, have full-text availability, target independent-living people aged 60 years and older from the general population, have an observational design, and assess the outcomes of a monitoring system based on energy (ie, electricity, gas, or water) usage on well-being and safety. The quality of the studies was assessed by the QualSyst systematic review tool.

RESULTS

The search strategy identified 2920 articles. The majority of studies focused on the technical algorithms underlying energy usage data and related sensors. One study was included in this review. This study reported that the smart energy meter data monitoring system was considered unobtrusive and was well accepted by the older people and professionals involved. Energy usage in a household acted as a unique signature and therefore provided useful insight into well-being and safety. This study lacked statistical power due to the small number of participants and the low number of observed events. In addition, the quality of the study was rated as low.

CONCLUSIONS

This review identified only 1 study that evaluated the impact of an energy usage monitoring system on the well-being and safety of older people. The absence of reliable evidence impedes any definitive guidance or recommendations for practice. Because this emerging field has not yet been studied thoroughly, many questions remain open for further research. Future studies should focus on the further development of a monitoring system and the evaluation of the implementation and outcomes of these systems.

TRIAL REGISTRATION

PROSPERO CRD42022245713; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=245713.

The association between the kyphosis angle and physical performance in community-dwelling older adults

BACKGROUND

We investigated prospectively among community-dwelling older adults aged 65 years and over whether a larger kyphosis angle is associated with poorer physical performance (balance, muscle strength or both), and whether this association is unidirectional.

METHODS

ale and female participants performed a multicomponent physical performance test with subscores for gait, muscle strength and balance at baseline and after 2 years. Hand grip strength was also measured at baseline and at follow-up. The Cobb angle was measured on DXA-based Vertebral Fracture Assessments, made at the baseline and follow-up visit. Through linear and logistic regression analysis, we investigated the association between the kyphosis angle and physical performance and vice versa. We stratified for sex, and tested for effect modification by age and study center.

RESULTS

The mean kyphosis angle was 37° and 15% of the participants (n=1220, mean age 72.9±5.7 years) had hyperkyphosis (Cobb angle ≥50°). A larger kyphosis angle at baseline was independently associated with a poorer total physical performance score in women of the oldest quartile (≥77 years) in both the cross-sectional and longitudinal analyses (baseline B-0.32, 95%CI -0.56--0.08; follow-up B 0.32, 95%CI -0.55--0.10). There was no association between physical performance at baseline and kyphosis progression.

CONCLUSIONS

A larger kyphosis angle is independently associated with a poorer physical performance at baseline and over time, and the direction of this association is unidirectional. These results emphasize the importance of early detection and treatment of hyperkyphosis to prevent further worsening of the kyphosis angle, thereby potentially preserving physical performance.

The association between hyperkyphosis and fall incidence among community-dwelling older adults

Hyperkyphosis, an increased kyphosis angle of the thoracic spine, was associated with a higher fall incidence in the oldest quartile of a large prospective cohort of community-dwelling older adults. Hyperkyphosis could serve as an indicator of an increased fall risk as well as a treatable condition.

INTRODUCTION

Hyperkyphosis is frequently found in adults aged 65 years and older and may be associated with falls. We aimed to investigate prospectively in community-dwelling older adults whether hyperkyphosis or change in the kyphosis angle is associated with fall incidence.

METHODS

Community-dwelling older adults (n = 1220, mean age 72.9 ± 5.7 years) reported falls weekly over 2 years. We measured thoracic kyphosis through the Cobb angle between the fourth and 12th thoracic vertebra on DXA-based vertebral fracture assessments and defined hyperkyphosis as a Cobb angle ≥ 50°. The change in the Cobb angle during follow-up was dichotomized (< 5 or ≥ 5°). Through multifactorial regression analysis, we investigated the association between the kyphosis angle and falls.

RESULTS

Hyperkyphosis was present in 15% of the participants. During follow-up, 48% of the participants fell at least once. In the total study population, hyperkyphosis was not associated with the number of falls (adjusted IRR 1.12, 95% CI 0.91-1.39). We observed effect modification by age (p = 0.002). In the oldest quartile, aged 77 years and older, hyperkyphosis was prospectively associated with a higher number of falls (adjusted IRR 1.67, 95% CI 1.14-2.45). Change in the kyphosis angle was not associated with fall incidence.

CONCLUSIONS

Hyperkyphosis was associated with a higher fall incidence in the oldest quartile of a large prospective cohort of community-dwelling older adults. Because hyperkyphosis is a partially reversible condition, we recommend investigating whether hyperkyphosis is one of the causes of falls and whether a decrease in the kyphosis angle may contribute to fall prevention.

STOPPFall (Screening Tool of Older Persons Prescriptions in older adults with high fall risk): a Delphi study by the EuGMS Task and Finish Group on Fall-Risk-Increasing Drugs

Background

Healthcare professionals are often reluctant to deprescribe fall-risk-increasing drugs (FRIDs). Lack of knowledge and skills form a significant barrier and furthermore, there is no consensus on which medications are considered as FRIDs despite several systematic reviews. To support clinicians in the management of FRIDs and to facilitate the deprescribing process, STOPPFall (Screening Tool of Older Persons Prescriptions in older adults with high fall risk) and a deprescribing tool were developed by a European expert group.

Methods

STOPPFall was created by two facilitators based on evidence from recent meta-analyses and national fall prevention guidelines in Europe. Twenty-four panellists chose their level of agreement on a Likert scale with the items in the STOPPFall in three Delphi panel rounds. A threshold of 70% was selected for consensus a priori. The panellists were asked whether some agents are more fall-risk-increasing than others within the same pharmacological class. In an additional questionnaire, panellists were asked in which cases deprescribing of FRIDs should be considered and how it should be performed.

Results

The panellists agreed on 14 medication classes to be included in the STOPPFall. They were mostly psychotropic medications. The panellists indicated 18 differences between pharmacological subclasses with regard to fall-risk-increasing properties. Practical deprescribing guidance was developed for STOPPFall medication classes.

Conclusion

STOPPFall was created using an expert Delphi consensus process and combined with a practical deprescribing tool designed to optimise medication review. The effectiveness of these tools in falls prevention should be further evaluated in intervention studies.

Shoe design for older adults: Evidence from a systematic review on the elements of optimal footwear

Due to changes in foot morphology and the occurrence of foot deformities and foot pain with ageing, older people frequently wear ill-fitting shoes. This can lead to discomfort and reduced mobility. A review of the literature was performed in Medline, Scopus and Embase with three aims: (a) to evaluate the effects of shoes or shoe elements on the comfort and mobility of older adults, (b) to summarise the evidence-based elements of a safe and comfortable shoe for older adults, and (c) from that, to compile those elements into design recommendations for a safe and comfortable shoe for older adults. Safe elements of footwear include proper anatomical fit, a well-fitting toe box, limited heel height, a broad enough heel, a firm insole and midsole, an outsole with sufficient tread, bevelled heel, firm heel counter with snug fit, and an easy and effective closing mechanism. We conclude that there is a need for shoe design specifically aimed at the foot morphology and demands of older people. The shoe market should increase the availability of well-fitting shoes designed for the older foot and person.

Electronic assistive technology for community-dwelling solo-living older adults: A systematic review

The proportion of older adults who live alone in single households is growing continuously. In the care of these solo-living older adults, electronic assistive technology (EAT) can play an important role. The objective of this review is to investigate the effects of EAT on the wellbeing of community-dwelling older adults living alone in single households. A systematic review of English articles was conducted based on PMC, Scopus, Web of Science and the Cochrane database. Additional studies were identified from the references. In total, 16 studies were identified, six of them with follow-up. There is evidence that EAT can improve the physical and mental wellbeing of older adults. There was little evidence that EAT can improve social wellbeing. We conclude that more personalized designs and interventions, and more user engagement could be embedded in the design of EAT for solo-living community-dwelling older adults and that more evidence is needed regarding the effects of those interventions.

Differences in potential biomarkers of delirium between acutely ill medical and elective cardiac surgery patients

BACKGROUND/AIMS

The pathophysiology of delirium is poorly understood. Increasing evidence suggests that different pathways might be involved in the pathophysiology depending on the population studied. The aim of the present study was to investigate potential differences in mean plasma levels of neopterin, amino acids, amino acid ratios and homovanillic acid between two groups of patients with delirium.

METHODS

Data from acutely ill medical patients aged 65 years and older, and patients aged 70 years and older undergoing elective cardiac surgery, were used. Differences in biomarker levels between the groups were investigated using univariate ANOVA with adjustments for age, sex, comorbidities, C-reactive protein (CRP) and the estimated glomerular filtration rate (eGFR), where appropriate. Linear regression analysis was used to identify potential determinants of the investigated biochemical markers.

RESULTS

Eighty patients with delirium were included (23 acutely ill medical patients and 57 elective cardiac surgery patients). After adjustment, higher mean neopterin levels (93.1 vs 47.3 nmol/L, P=0.001) and higher phenylalanine/tyrosine ratios (1.39 vs 1.15, P=0.032) were found in acutely ill medical patients when compared to elective cardiac surgery patients. CRP levels were positively correlated with neopterin levels in acutely ill medical patients, explaining 28.4% of the variance in neopterin levels. eGFR was negatively correlated with neopterin in elective cardiac surgery patients, explaining 53.7% of the variance in neopterin levels.

CONCLUSION

In this study, we found differences in mean neopterin levels and phenylalanine/tyrosine ratios between acutely ill medical and elective cardiac surgery patients with delirium. Moreover, our findings may suggest that in acutely ill medical patients, neopterin levels are mainly determined by inflammation/oxidative stress whereas in elective cardiac surgery patients, neopterin levels are mainly driven by renal function/fluid status. These findings suggest that the markers and pathways that might be involved in the pathophysiology of delirium may differ between specific groups of patients.

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.

Mortality From Falls in Dutch Adults 80 Years and Older, 2000-2016

This study uses national statistics to characterize trends in mortality from falls in persons aged 80 years and older between 2000 and 2016 in the Netherlands.

Association of estimated glomerular filtration rate with muscle function in older persons who have fallen

Background

studies suggest that estimated glomerular filtration rate (eGFR) is less reliable in older persons and that a low serum-creatinine might reflect reduced muscle mass rather than high kidney function. This study investigates the possible relationship between eGFR and multiple elements of physical performance in older fallers.

Methods

baseline data of the IMPROveFALL-study were examined in participants ≥65 years. Serum-creatinine based eGFR was classified as normal (≥90 ml/min), mildly reduced (60-89 ml/min) or moderately-severely reduced (<60 ml/min). Timed-Up-and-Go-test and Five-Times-Sit-to-Stand-test were used to assess mobility; calf circumference and handgrip strength to assess muscle status. Ancova models adjusted for age, sex, Charlson comorbidity index and body mass index were performed.

Results

a total of 578 participants were included. Participants with a normal eGFR had lower handgrip strength than those with a mildly reduced eGFR (-9.5%, P < 0.001) and those with a moderately-severely reduced eGFR (-6.3%, P = 0.033) with mean strengths of 23.4, 25.8 and 24.9 kg, respectively. Participants with a normal eGFR had a smaller calf circumference than those with a mildly reduced eGFR (35.5 versus 36.5 cm, P = 0.006). Mean time to complete the mobility tests did not differ.

Conclusions

in this study we found that older fallers with an eGFR ≥ 90 ml/min had smaller calf circumference and up to 10% lower handgrip strength than those with a reduced eGFR. This lower muscle mass is likely to lead to an overestimation of kidney function. This outcome therefore supports the search for biomarkers independent of muscle mass to estimate kidney function in older persons.

Effectiveness of medication withdrawal in older fallers: results from the Improving Medication Prescribing to reduce Risk Of FALLs (IMPROveFALL) trial

Objectives

To investigate the effect of withdrawal of fall-risk-increasing-drugs (FRIDs) versus ‘care as usual’ on reducing falls in community-dwelling older fallers.

Design

Randomised multicentre trial

Participants

Six hundred and twelve older adults who visited an Emergency Department (ED) because of a fall.

Interventions

Withdrawal of FRIDs.

Main Outcomes and Measures

Primary outcome was time to the first self-reported fall. Secondary outcomes were time to the second self-reported fall and to falls requiring a general practitioner (GP)-consultation or ED-visit. Intention-to-treat (primary) and a per-protocol (secondary) analysis were conducted. The hazard ratios (HRs) for time-to-fall were calculated using a Cox-regression model. Differences in cumulative incidence of falls were analysed using Poisson regression.

Results

During 12 months follow-up, 91 (34%) control and 115 (37%) intervention participants experienced a fall; 35% of all attempted interventions were unsuccessful, either due to recurrence of the initial indication for prescribing, additional medication for newly diagnosed conditions or non-compliance. Compared to baseline, the overall percentage of users of ≥3 FRIDs at 12 months did not change in either the intervention or the control group. Our intervention did not have a significant effect on time to first fall (HR 1.17; 95% confidence interval 0.89–1.54), time to second fall (1.19; 0.78–1.82), time to first fall-related GP-consultation (0.66; 0.42–1.06) or time to first fall-related ED-visit (0.85; 0.43–1.68).

Conclusion

In this population of complex multimorbid patients visiting an ED because of a fall, our single intervention of FRIDs-withdrawal was not effective in reducing falls.

Trial Registration

Netherlands Trial Register NTR1593.

New horizons in design for autonomous ageing

The world is ageing rapidly. Between 2000 and 2050, the number of people aged ≥65 will double as a proportion of the global population, from 7% to 16%, respectively. By 2050, for the first time in human history, there will be more older people than children (aged 0–14 years) in the population. More distinctive is the tremendous increase in the oldest old aged ≥85. This challenges society to adapt, in order to maximise the health and functional capacity of older people as well as their social participation and security. Ageing is a multidimensional process of change in the physical, mental and social domain, leading to functional decline. Design thinking has embraced ageing as a topic where it can add to public health interventions. Applications of design and technology can contribute to ‘autonomous ageing’, for example, independent living and life style support, and can compensate for functional deficits associated with ageing. The focus is on supporting and reinforcing the reduced physical, mental, social and functional capacities of older people by applying groundbreaking, innovative design inclusive engineering methods, always starting with a human-centered integrated approach. Examples of design for geriatric giants include design for falls prevention, dementia care and integrated care. The establishment of collaborative networks between clinicians and designers, academia and industry is required to advance design for autonomous ageing.

Drug-induced falls in older persons: is there a role for therapeutic drug monitoring?

BACKGROUND

Falls are the leading cause of injuries among older persons. Because of ageing societies worldwide, falls are expected to become a prominent public health problem. The usage of several types of drugs has been associated with an increased fall and fracture risk. In order to reduce future falls, preventative measures are needed. Therapeutic drug monitoring may help to identify persons who are at risk for falls due to drug use. The aim was to demonstrate how drugs can contribute to falls and the role of therapeutic drug monitoring.

METHODS

We present a descriptive case series of four patients.

RESULTS

All patients were referred to the geriatric outpatient clinic of a university medical center. The presented cases contained different underlying mechanisms contributing to an increased fall risk in older adults, including renal failure, genetic variation, overdose and ageing.

CONCLUSION/DISCUSSION

Older adults are more prone to the side effects of drug use, including falls. Therapeutic drug monitoring may be useful to identify the patients who have an increased drug-related fall risk and to prevent future falls by individualizing the drug regime.

Disturbed Serotonergic Neurotransmission and Oxidative Stress in Elderly Patients with Delirium

Background

Oxidative stress and disturbances in serotonergic and dopaminergic neurotransmission may play a role in the pathophysiology of delirium.

Aims

In this study, we investigated levels of amino acids, amino acid ratios and levels of homovanillic acid (HVA) as indicators for oxidative stress and disturbances in neurotransmission.

Methods

Plasma levels of amino acids, amino acid ratios and HVA were determined in acutely ill patients aged ≥65 years admitted to the wards of Internal Medicine and Geriatrics of the Erasmus University Medical Center and the ward of Geriatrics of the Havenziekenhuis, Rotterdam, The Netherlands. Differences in the biochemical parameters between patients with and without delirium were investigated by analysis of variance in models adjusted for age, gender and comorbidities.

Results

Of the 86 patients included, 23 had delirium. In adjusted models, higher mean phenylalanine/tyrosine ratios (1.34 vs. 1.14, p = 0.028), lower mean tryptophan/large neutral amino acids ratios (4.90 vs. 6.12, p = 0.021) and lower mean arginine levels (34.8 vs. 45.2 µmol/l, p = 0.022) were found in patients with delirium when compared to those without. No differences were found in HVA levels between patients with and without delirium.

Conclusion

The findings of this study suggest disturbed serotonergic neurotransmission and an increased status of oxidative stress in patients with delirium.

Neopterin: a potential biomarker for delirium in elderly patients

BACKGROUND/AIMS

The diagnosis of delirium is not supported by specific biomarkers. In a previous study, high neopterin levels were found in patients with a postoperative delirium. In the present study, we investigated levels of neopterin, interleukin-6 (IL-6) and insulin-like growth factor-1 (IGF-1) in acutely ill admitted elderly patients with and without a delirium.

METHODS

Plasma/serum levels of neopterin, IL-6 and IGF-1 were determined in patients aged ≥65 years admitted to the wards of Internal Medicine and Geriatrics. Differences in biomarker levels between patients with and without a delirium were investigated by the analysis of variance in models adjusted for age, gender, comorbidities and eGFR (when appropriate).

RESULTS

Eighty-six patients were included; 23 of them with a delirium. In adjusted models, higher mean levels of neopterin (70.5 vs. 45.9 nmol/l, p = 0.009) and IL-6 (43.1 vs. 18.5 pg/ml, p = 0.034) and lower mean levels of IGF-1 (6.3 vs. 9.3 nmol/l, p = 0.007) were found in patients with a delirium compared to those without.

CONCLUSIONS

The findings of this study suggest that neopterin might be a potential biomarker for delirium which, through oxidative stress and activation of the immune system, may play a role in the pathophysiology of delirium.

Effect of Vitamin B12 and Folic Acid Supplementation on Bone Mineral Density and Quantitative Ultrasound Parameters in Older People with an Elevated Plasma Homocysteine Level: B-PROOF, a Randomized Controlled Trial

High plasma homocysteine (Hcy) levels are associated with increased osteoporotic fracture incidence. However, the mechanism remains unclear. We investigated the effect of Hcy-lowering vitamin B12 and folic acid treatment on bone mineral density (BMD) and calcaneal quantitative ultrasound (QUS) parameters. This randomized, double-blind, placebo-controlled trial included participants aged ≥65 years with plasma Hcy levels between 12 and 50 µmol/L. The intervention comprised 2-year supplementation with either a combination of 500 µg B12, 400 µg folic acid, and 600 IU vitamin D or placebo with 600 IU vitamin D only. In total, 1111 participants underwent repeated dual-energy X-ray assessment and 1165 participants underwent QUS. Femoral neck (FN) BMD, lumbar spine (LS) BMD, calcaneal broadband ultrasound attenuation (BUA), and calcaneal speed of sound (SOS) were assessed. After 2 years, FN-BMD and BUA had significantly decreased, while LS-BMD significantly increased (all p < 0.01) and SOS did not change in either treatment arm. No statistically significant differences between the intervention and placebo group were present for FN-BMD (p = 0.24), LS-BMD (p = 0.16), SOS (p = 0.67), and BUA (p = 0.96). However, exploratory subgroup analyses revealed a small positive effect of the intervention on BUA at follow-up among compliant persons >80 years (estimated marginal mean 64.4 dB/MHz for the intervention group and 61.0 dB/MHz for the placebo group, p = 0.04 for difference). In conclusion, this study showed no overall effect of treatment with vitamin B12 and folic acid on BMD or QUS parameters in elderly, mildly hyperhomocysteinemic persons, but suggests a small beneficial effect on BUA in persons >80 years who were compliant in taking the supplement.

Associations between medication use and homocysteine levels in an older population, and potential mediation by vitamin B12 and folate: data from the B-PROOF Study

BACKGROUND

Elevated homocysteine levels are a risk indicator for cardiovascular disease, fractures and cognitive decline. Previous studies indicated associations between homocysteine levels and medication use, including antihypertensive, lipid-lowering and antidiabetic medication. However, results were often contradictory and inconclusive. Our objective was to study the associations established previously in more detail by sub-classifying medication groups, and investigate the potential mediating role of vitamin B12 and folate status.

MATERIALS AND METHODS

Baseline data from the B-PROOF (B-vitamins for the PRevention Of Osteoporotic Fractures) study were used. We included 2,912 participants aged ≥65 years, with homocysteine levels of 12-50 μmol/L and creatinine levels ≤150 μmol/L, for whom self-reported medication data were available. We used multivariable linear regression models and analysis of covariance to assess the association between medication use and plasma homocysteine levels, and the potential mediation by serum vitamin B12 and folate.

RESULTS

The mean age was 74 years (standard deviation, 6.5), 50 % were women, and median homocysteine levels were 14 µmol/L [interquartile range, 13-17 µmol/L]. Higher mean homocysteine levels were observed in users vs. non-users for diuretics (15.2 vs. 14.9, p = 0.043), high-ceiling sulphonamide diuretics (16.0 vs. 14.9, p < 0.001), medication acting via the renin-angiotensin system (15.2 vs. 14.9, p = 0.029) and metformin (15.6 vs. 15.1, p = 0.006). Non-selective β-blocker use was associated with lower mean homocysteine levels (14.4 vs. 15.0, p = 0.019). Only this association was mediated by an underlying association with vitamin B12 and folate levels.

CONCLUSION

The associations between homocysteine levels and medication use appear to be fairly modest. Our results suggest that medication use is unlikely to contribute to clinically relevant changes in plasma homocysteine levels.

[Detecting inappropriate medication in older people: the revised STOPP/START criteria]

The use of potentially inappropriate medications (PIMs) by older people and potential prescribing omissions (PPOs) represent a serious problem. It increases the risk of adverse drug reactions (ADRs), however it is susceptible to influence in a substantial number of cases. Use of the STOPP/START criteria developed in Ireland to optimise pharmacotherapy of older people reduces the number of ADRs and medication errors. Licensing of new drugs, the increased number of potentially inappropriate drugs, and the availability of new literature were grounds for an update of the first version of the STOPP/START criteria which was published in 2008. In order to develop a screening tool with a broader application, a consensus panel of experts in the field of pharmacotherapy of older people was selected from 14 European countries for the second version of the STOPP/START criteria, including two from the Netherlands. The translation of the second version of the STOPP/START criteria has been adapted to the situation in the Netherlands, partly by omitting drugs that are not licensed in the Netherlands.

Results of 2-year vitamin B treatment on cognitive performance: secondary data from an RCT

OBJECTIVE

We investigated the effects of 2-year folic acid and vitamin B12 supplementation on cognitive performance in elderly people with elevated homocysteine (Hcy) levels.

METHODS

This multicenter, double-blind, randomized, placebo-controlled trial included 2,919 elderly participants (65 years and older) with Hcy levels between 12 and 50 µmol/L. Participants received daily either a tablet with 400 µg folic acid and 500 µg vitamin B12 (B-vitamin group) or a placebo tablet. Both tablets contained 15 µg vitamin D3. Data were available for global cognitive functioning assessed by Mini-Mental State Examination (n = 2,556), episodic memory (n = 2,467), attention and working memory (n = 759), information processing speed (n = 731), and executive function (n = 721).

RESULTS

Mean age was 74.1 (SD 6.5) years. Hcy concentrations decreased 5.0 (95% confidence interval -5.3 to -4.7) µmol/L in the B-vitamin group and 1.3 (-1.6 to -0.9) µmol/L in the placebo group. Cognitive domain scores did not differ over time between the 2 groups, as determined by analysis of covariance. Mini-Mental State Examination score decreased with 0.1 (-0.2 to 0.0) in the B-vitamin group and 0.3 (-0.4 to -0.2) in the placebo group (p = 0.05), as determined by an independent t test.

CONCLUSIONS

Two-year folic acid and vitamin B12 supplementation did not beneficially affect performance on 4 cognitive domains in elderly people with elevated Hcy levels. It may slightly slow the rate of decline of global cognition, but the reported small difference may be attributable to chance.

CLASSIFICATION OF EVIDENCE

This study provides Class I evidence that 2-year supplementation with folic acid and vitamin B12 in hyperhomocysteinemic elderly people does not affect cognitive performance.

Do lifestyle, health and social participation mediate educational inequalities in frailty worsening?

BACKGROUND

Lower educated older persons are at increased risk of becoming frail as compared with higher educated older persons. To reduce educational inequalities in the development of frailty, we investigated whether lifestyle, health and social participation mediate this relationship.

METHODS

Longitudinal data of 14 082 European community-dwelling persons aged 55 years and older participating in the Survey on Health, Ageing, and Retirement in Europe (SHARE) in 2004 and 2006, were used. Associations of lifestyle (smoking behaviour and alcohol consumption), health (depression, memory function, chronic diseases) and social participation, with educational level and frailty worsening were investigated using regression models. In multinomial logistic regression analysis, mediators were added to models in which educational level was associated with worsening in frailty over 2 years follow-up.

RESULTS

In all countries, frailty worsening was more prevalent among lower as compared with higher educated persons, although odds ratios were only statistically significant in five of the 11 countries included [ORs varying from 1.40 (95% CI: 1.06-1.84) to 1.61 (95% CI: 1.21-2.14)]. Except for smoking behaviour and memory function, the factors under study all showed associations with educational level and frailty worsening that met the conditions for mediation. After inclusion of the four relevant mediators, attenuation of odds ratios varied between 4.9 and 31.5%.

CONCLUSION

While lifestyle, health and social participation were associated with frailty worsening over 2 years among European community-dwelling older persons, only small to moderate parts of educational inequalities in frailty worsening were explained by these factors.

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.

Vitamin D and physical performance in older men and women visiting the emergency department because of a fall: data from the improving medication prescribing to reduce risk of falls (IMPROveFALL) study

OBJECTIVES

To investigate whether serum 25-hydroxy vitamin D (25(OH)D) is associated with physical performance in men and women.

DESIGN

Cross-sectional.

SETTING

Emergency departments (EDs) of five hospitals.

PARTICIPANTS

Older adults who visited an ED because of a fall (N = 616).

MEASUREMENTS

Physical performance was assessed using the Timed Up and Go Test, the Five Time Sit to Stand Test, handgrip strength, and the tandem stand test. Multivariate linear regression was used to assess the association between physical performance and log-transformed 25(OH)D concentration adjusted for potential confounders.

RESULTS

In men, higher serum 25(OH)D concentration was significantly associated with better handgrip strength (regression coefficient (B) = 3.86, 95% confidence interval (CI) = 2.04-5.69), faster TUG time (B = -2.82, 95% CI = -4.91 to -0.73), and faster FTSS time (B = -3.39, 95% CI = -5.67 to -1.11). In women, higher serum 25(OH)D concentration was significantly associated with faster TUG time (B = -2.68, 95% CI = -4.87 to -0.49).

CONCLUSION

A positive association was found between serum 25(OH)D level and physical performance in men and women. Intervention studies are needed of vitamin D-deficient older men and women to further investigate the effect of vitamin D supplementation in this group.

Risk of death among persons with Alzheimer's disease: a national register-based nested case-control study

Few studies have reported the risk of death related to Alzheimer's disease (AD) in large population-based cohorts. The objective of this study was to analyze the impact of AD on all-cause mortality in a nationwide sample of persons with AD. Community-dwelling persons with AD and an equal number of individually matched (age, gender, and region of residence) control persons without AD were identified from the registers of Social Insurance Institution of Finland at the end of 2005. Deaths in this sample (n = 56,041, mean age 79.7 years, 67.8% women) during a 57-month follow-up period were recorded. Using a nested case-control design, unadjusted and adjusted (cardiovascular disease, cancer, diabetes, and asthma and/or COPD) hazard ratios (HR) with 95% confidence intervals (CI) were computed using proportional hazards regression. The results were categorized according to age at death (<80, 80 to 89, ≥ 90 years) and duration of AD (≤ 3, 4 to 6, ≥ 7 years). The unadjusted HR for death associated with AD was 2.03 (95% CI: 1.97 to 2.09). The HR was highest in the youngest age category [HR = 3.46 (95% CI: 3.18 to 3.77)], and still significantly elevated in the oldest age category [HR = 1.50 (95% CI: 1.41 to 1.60)]. Comorbidity adjustments did not change the HRs, and even a short duration of AD (≤ 3 years) was associated with a significantly increased risk of death. In conclusion, AD was associated with an increased risk of death that was more pronounced at younger ages and existed even after a recent diagnosis of AD.

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.

Visuomotor impairment in early-stage Alzheimer's disease: changes in relative timing of eye and hand movements

Although memory complaints are one of the first clinical symptoms in patients with Alzheimer's disease (AD), damage to the parietal lobe, a key structure in the visuomotor coordination network, was recently identified in early-stage AD. The aim of this study was to quantify visuomotor coordination in patients with probable AD and to compare their visuomotor performance with controls using five eye-hand coordination tasks of variable complexity. Eye and hand movements were measured in 16 AD patients and 18 controls. The measurement setup consisted of a touch screen, an eye-tracking device, and a motion capturing system. We investigated eye-hand coordination by quantifying absolute and relative latencies of eye and hand movements and by analyzing eye and hand kinematics. We found that AD patients need significantly more time to initiate and execute goal-directed hand movements. AD patients are also unable to suppress reflexive eye and, to a lesser extent, hand movements. Furthermore, AD patients use a stepwise approach of eye and hand movements to touch a sequence of stimuli, whereas controls more often show an anticipatory approach. The impairments in reflex suppression of eye and hand movements, and changes in relative timing of eye-hand coordination, in AD patients support the notion that cortical networks involving the posterior parietal cortex are affected at an early disease-stage. It also suggests that the problems of AD patients to perform daily activities that require eye-hand coordination are not only caused by cognitive decline, but also by degeneration of neural networks involved in visuomotor coordination.

Dose-response relationship between selective serotonin re-uptake inhibitors and injurious falls: a study in nursing home residents with dementia

AIM

The contribution of selective serotonin re-uptake inhibitors (SSRIs) to injurious fall risk in patients with dementia has not been quantified precisely until now. Our objective was to determine whether a dose-response relationship exists for the use of SSRIs and injurious falls in a population of nursing home residents with dementia.

METHODS

Daily drug use and daily falls were recorded in 248 nursing home residents with dementia from 1 January 2006 until 1 January 2008. For each resident and for each day of the study period, data on drug use were abstracted from the prescription database, and information on falls and subsequent injuries was retrieved from a standardized incident report system, resulting in a dataset of 85,074 person-days.

RESULTS

We found a significant dose-response relationship between injurious falls and the use of SSRIs. The risk of an injurious fall increased significantly with 31% at 0.25 of the Defined Daily Dose (DDD) of a SSRI, 73% at 0.50 DDD, and 198% at 1.00 DDD (Hazard ratio = 2.98; 95% confidence interval 1.94, 4.57). The risk increased further in combination with a hypnotic or sedative.

CONCLUSIONS

Even at low doses, SSRIs are associated with increased risk of an injurious fall in nursing home residents with dementia. Higher doses increase the risk further with a three-fold risk at 1.00 DDD. New treatment protocols might be needed that take into account the dose-response relationship between SSRIs and injurious falls.

Assessment and treatment of malnutrition in Dutch geriatric practice: consensus through a modified Delphi study

OBJECTIVE

scientific evidence regarding the optimal management of malnutrition in geriatric patients is scarce. Our aim was to develop a consensus statement for geriatric hospital practice concerning six elements: (i) definition of malnutrition, (ii) screening and assessment, (iii) treatment and monitoring, (iv) roles and responsibilities of involved health care professionals, (v) communication and coordination of care between hospital and community health care professionals, (vi) quality indicators for malnutrition management.

DESIGN

a modified Delphi study.

METHODS

eleven geriatricians with special interest in malnutrition participated. In four rounds the experts rated the relevance of 204 statements, which were based on a literature review, on a five-point Likert scale. From the responses, means and 95% CIs were calculated. Consensus was defined as a lower 95% confidence limit ≥4.0.

RESULTS

the panel reached consensus that malnutrition should be considered a geriatric syndrome. The nutritional status should be assessed using the Mini Nutritional Assessment combined with comprehensive geriatric assessment. Nutritional interventions should be combined with interventions targeting underlying factors. Specific goals for nutritional therapy and ways to achieve them were agreed upon. According to the experts, malnutrition is best managed by a multidisciplinary team for whom roles and responsibilities were specified. At discharge written information about the nutritional problem, treatment plan and goals should be provided to the patient, caregiver and community health care professionals.

CONCLUSION

this study shows that a qualitative study based on a modified Delphi technique can result in national consensus on essential ingredients for a practical malnutrition guideline for geriatric patients.

End of the spectacular decrease in fall-related mortality rate: men are catching up

OBJECTIVES

We determined time trends in numbers and rates of fall-related mortality in an aging population, for men and women.

METHODS

We performed secular trend analysis of fall-related deaths in the older Dutch population (persons aged 65 years or older) from 1969 to 2008, using the national Official-Cause-of-Death-Statistics.

RESULTS

Between 1969 and 2008, the age-adjusted fall-related mortality rate decreased from 202.1 to 66.7 per 100,000 older persons (decrease of 67%). However, the annual percentage change (change per year) in mortality rates was not constant, and could be divided into 3 phases: (1) a rapid decrease until the mid-1980s (men -4.1%; 95% confidence interval [CI] = -4.9, -3.2; women -6.5%; 95% CI, -7.1, -5.9), (2) flattening of the decrease until the mid-1990s (men -1.4%; 95% CI = -2.4, -0.4; women -2.0%; 95% CI = -3.4, -0.6), and (3) stable mortality rates for women (0.0%; 95% CI = -1.2, 1.3) and rising rates for men (1.9%; 95% CI = 0.6, 3.2) over the last decade.

CONCLUSIONS

The spectacular decrease in fall-related mortality ended in the mid-1990s and is currently increasing in older men at similar rates to those seen in women. Because of the aging society, absolute numbers in fall-related deaths are increasing rapidly.

Emergency department visits due to vertebral fractures in the Netherlands, 1986-2008: steep increase in the oldest old, strong association with falls

BACKGROUND

Vertebral fractures are a common consequence of osteoporosis in older persons. With the ageing of the population, numbers are expected to rise.

OBJECTIVE

To determine trends in health care demand due to vertebral fracture related emergency department (ED) visits and hospitalizations in the older Dutch population.

DESIGN AND SETTING

Secular trend analysis of vertebral fracture related ED visits between 1986 and 2008, using the Dutch Injury Surveillance System. All ED visits with a primary diagnosis of a vertebral fracture in persons aged ≥65 years were extracted from this database.

MAIN OUTCOME MEASURE

Numbers, age-specific and age-adjusted incidence rates (per 100,000 population) of ED visits and hospitalization rates due to vertebral fractures in the older Dutch population were calculated for each year of the study.

RESULTS

The total number of ED visits due to a vertebral fracture increased from 913 in 1986 to 2502 in 2008 (174% increase). The majority of fractures were caused by a low-energetic fall incident (83%). The overall age-adjusted incidence rate increased from 51.6 per 100,000 population in 1986 to 103.6 in 2008. Incidence rates increased with age and were higher in females than in males. The hospitalization rate remained stable at about 50-55%, in both females and males.

CONCLUSION

Vertebral fracture related ED visits and hospitalizations are increasing rapidly in the older Dutch population, especially in the oldest-old. Most vertebral fractures were associated with falls. These findings indicate that a pro-active approach in the diagnosis and treatment of osteoporosis and in the prevention of falls in both men and women is warranted.

Why older people refuse to participate in falls prevention trials: a qualitative study

BACKGROUND/OBJECTIVES

Falls are a major public health problem. Older persons are frequently underrepresented in trials, including falls prevention trials. Insight into possible reasons for non-participation could help to improve trial designs and participation rates among this age-group. The aim of this study was to explore reasons why older people refuse to participate in falls prevention trials.

SETTING

A qualitative study.

PARTICIPANTS

Community-dwelling adults aged ≥65 years who attended the Emergency Department due to a fall and refused to participate in a falls prevention trial (IMPROveFALL-study).

MEASUREMENTS

A structured interview guide was used, and interview transcripts were subjected to an independent content analysis by two researchers.

RESULTS

15 interviews were conducted. A main reason to refuse trial participation was mobility impairment. In contrast, younger and more "active" and mobile seniors considered themselves "too healthy" to participate. Persons with multiple comorbidities mentioned that they attended a hospital too often, or experienced adequate follow-up by their own physicians already. Transport problems, including distance to the hospital, parking facilities, and travel expenses were another issue. During the interviews it was emphasized by the patients, that they knew the reason for their fall. However, they were not familiar with the positive effects of falls prevention programmes.

CONCLUSIONS

Older persons reported multiple reasons to refuse participation in a falls prevention study, such as health-related factors, several practical problems, and personal beliefs about the causes and preventability of falls. Anticipation of those issues might contribute to an improvement in participation rates of older fallers, shorter study duration, and a better generalizability of research findings.

The epidemic of hip fractures: are we on the right track?

BACKGROUND

Hip fractures are a public health problem, leading to hospitalization, long-term rehabilitation, reduced quality of life, large healthcare expenses, and a high 1-year mortality. Especially older adults are at greater risk of fractures than the general population, due to the combination of an increased fall risk and osteoporosis. The aim of this study was to determine time trends in numbers and incidence rates of hip fracture-related hospitalizations and admission duration in the older Dutch population.

METHODS AND FINDINGS

Secular trend analysis of all hospitalizations in the older Dutch population (≥65 years) from 1981 throughout 2008, using the National Hospital Discharge Registry. Numbers, age-specific and age-adjusted incidence rates (per 10,000 persons) of hospital admissions and hospital days due to a hip fracture were used as outcome measures in each year of the study. Between 1981 and 2008, the absolute number of hip fractures doubled in the older Dutch population. Incidence rates of hip fracture-related hospital admissions increased with age, and were higher in women than in men. The age-adjusted incidence rate increased from 52.0 to 67.6 per 10,000 older persons. However, since 1994 the incidence rate decreased (percentage annual change -0.5%, 95% CI: -0.7; -0.3), compared with the period 1981-1993 (percentage annual change 2.3%, 95% CI: 2.0; 2.7). The total number of hospital days was reduced by a fifth, due to a reduced admission duration in all age groups. A possible limitation was that data were obtained from a linked administrative database, which did not include information on medication use or co-morbidities.

CONCLUSIONS

A trend break in the incidence rates of hip fracture-related hospitalizations was observed in the Netherlands around 1994, possibly as a first result of efforts to prevent falls and fractures. However, the true cause of the observation is unknown.

Adverse drug reactions related hospital admissions in persons aged 60 years and over, The Netherlands, 1981-2007: less rapid increase, different drugs

BACKGROUND

Epidemiologic information on time trends of Adverse Drug Reactions (ADR) and ADR-related hospitalizations is scarce. Over time, pharmacotherapy has become increasingly complex. Because of raised awareness of ADR, a decrease in ADR might be expected. The aim of this study was to determine trends in ADR-related hospitalizations in the older Dutch population.

METHODOLOGY AND PRINCIPAL FINDINGS

Secular trend analysis of ADR-related hospital admissions in patients ≥60 years between 1981 and 2007, using the National Hospital Discharge Registry of The Netherlands. Numbers, age-specific and age-adjusted incidence rates (per 10,000 persons) of ADR-related hospital admissions were used as outcome measures in each year of the study. Between 1981 and 2007, ADR-related hospital admissions in persons ≥60 years increased by 143%. The overall standardized incidence rate increased from 23.3 to 38.3 per 10,000 older persons. The increase was larger in males than in females. Since 1997, the increase in incidence rates of ADR-related hospitalizations flattened (percentage annual change 0.65%), compared to the period 1981-1996 (percentage annual change 2.56%).

CONCLUSION/SIGNIFICANCE

ADR-related hospital admissions in older persons have shown a rapidly increasing trend in The Netherlands over the last three decades with a temporization since 1997. Although an encouraging flattening in the increasing trend of ADR-related admissions was found around 1997, the incidence is still rising, which warrants sustained attention to this problem.

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.

Trends in fall-related hospital admissions in older persons in the Netherlands

BACKGROUND

Fall-related injuries, hospitalizations, and mortality among older persons represent a major public health problem. Owing to aging societies worldwide, a major impact on fall-related health care demand can be expected. We determined time trends in numbers and incidence of fall-related hospital admissions and in admission duration in older adults.

METHODS

Secular trend analysis of fall-related hospital admissions in the older Dutch population from 1981 through 2008, using the National Hospital Discharge Registry. All fall-related hospital admissions in persons 65 years or older were extracted from this database. Outcome measures were the numbers, and the age-specific and age-adjusted incidence rates (per 10,000 persons) of fall-related hospital admissions in each year of the study.

RESULTS

From 1981 through 2008, fall-related hospital admissions increased by 137%. The annual age-adjusted incidence growth was 1.3% for men vs 0.7% for women (P < .001). The overall incidence rate increased from 87.7 to 141.2 per 10,000 persons (an increase of 61%). Age-specific incidence increased in all age groups, in both men and women, especially in the oldest old (>75 years). Although the incidence of fall-related hospital admissions increased, the total number of fall-related hospital days was reduced by 20% owing to a reduction in admission duration.

CONCLUSIONS

In the Netherlands, numbers of fall-related hospital admissions among older persons increased drastically from 1981 through 2008. The increasing fall-related health care demand has been compensated for by a reduced admission duration. These figures demonstrate the need for implementation of falls prevention programs to control for increases of fall-related health care consumption.

High systolic and pulse pressure levels are associated with better cognitive performance in patients with probable Alzheimer's disease: a cross-sectional observational study in a geriatric outpatient population

BACKGROUND

The prevalence of cardiovascular disease and Alzheimer's disease (AD) increases with age. A number of studies have demonstrated an association between AD and cardiovascular risk factors and disease. However, data are inconsistent.

METHODS

Cross-sectional observational study in a geriatric outpatient population. Analysis of data from 327 patients diagnosed with probable AD in a geriatric outpatient clinic. Comparison of blood pressure levels, cardiovascular diagnoses, and Mini-Mental State Examination (MMSE) score between the patients.

RESULTS

MMSE score decreased with age (beta = -0.25; 95% CI: -0.35 to 0.15), and a positive correlation was found with systolic blood pressure (beta = 0.03; 95% CI: 0.003-0.06), pulse pressure (beta = 0.05; 95% CI: 0.01-0.08) and hypertension (beta = 1.56; 95% CI: 0.05-3.07). An increase in cardiovascular disease load had a negative effect on cognitive performance. After adjustment for duration of dementia (data present for 216 patients), results were slightly changed.

CONCLUSIONS

Higher systolic blood pressure and pulse pressure were associated with a better cognitive test performance. Patients with probable AD and 2 or more cardiovascular diagnoses had lower MMSE scores.

[Melanomas more serious in the elderly]

Two patients, a 96-year-old woman and a 94-year-old man, were diagnosed with metastatic cutaneous melanoma. The first patient had undergone radical excision of the primary tumour 18 months before. The second patient presented with neurological symptoms caused by a metastatic melanoma; the primary tumour had recently been resected. Both patients died within three weeks of the diagnosis. Cutaneous melanomas have a high metastatic rate. Treatment options are limited for metastatic disease. The incidence of melanoma increases with age. Old age is an independent risk factor, which is also associated with a poor prognosis. Older patients more often present with more serious histological characteristics and more aggressive types of melanoma. The Breslow thickness is also higher in patients aged 65 or over. Nodular melanoma, lentigo maligna or acral lentiginous melanoma are observed more frequently in this group of patients. Moreover, elderly people more frequently present with liver or cerebral metastases. Early diagnosis improves the prognosis, also in the elderly.

CYP2D6*4, CYP3A5*3 and ABCB1 3435T polymorphisms and drug-related falls in elderly people

OBJECTIVE

The objective of this study is to investigate the association between CYP2D6*4, CYP3A5*3 and ABCB1 3435T polymorphisms and drug-related falls.

METHOD

Multivariate logistic regression was performed in an existing database in order to study the association between falls history and CYP2D6*4, CYP3A5*3, ABCB1 3435T polymorphisms in patients using fall-risk-increasing CYP2D6, CYP3A5 and P-glycoprotein (gene product of ABCB1) substrates.

RESULTS

No statistically significant increased fall risk was found in 'poor metabolizers' compared to 'extensive' and 'intermediate metabolizers' using fall-risk-increasing CYP2D6 substrates (Odds ratio (OR) = 2.2; 95% confidence interval (CI) 0.2-25.0), CYP3A5 substrates (OR = 0.9; 95% CI 0.2-3.3) and P-glycoprotein substrates (OR = 2.1; 95% CI 0.2-17.2).

CONCLUSION

The hypothesis that 'poor metabolizers' have an increased fall risk was not confirmed. A larger study population is needed to confirm the potential association that was seen between CYP2D6*4 and ABCB1 3435T polymorphisms and drug-related falls.

Associations between plasma natriuretic peptides and echocardiographic abnormalities in geriatric outpatients

Identification of patients with cardiac dysfunction can be difficult in the geriatric population. Recently, different subtypes of the natriuretic peptide family have been advocated as biomarker for the diagnosis of heart failure in the emergency department setting. In this study we looked at associations between natriuretic peptide plasma levels and echocardiographic abnormalities in geriatric outpatients. Two-dimensional transthoracic echocardiography was performed in 209 community-dwelling subjects, visiting the geriatric outpatient clinic of our university hospital. Subjects were 65 years or older and had no markedly impaired cognitive function. Mean atrial natriuretic peptide (ANP) and B-type natriuretic peptide (BNP) plasma levels were respectively 11.0 and 10.8 pmol/l. BNP, but not ANP correlated with left ventricular dysfunction and left ventricular mass, whereas both peptides correlated with left atrial dimension and valvular lesions. A natriuretic peptide level in the highest tertile was associated with a higher risk of any echocardiographic abnormality, with odds ratios for BNP of 7.15 (range 2.15-23.71), and for ANP of 3.07 (range 1.15-8.16). In conclusion, elevated BNP and ANP plasma levels are closely related to cardiac abnormalities in elderly subjects. The association between cardiac abnormalities and natriuretic peptides is stronger for BNP than for ANP, hence for detection of cardiac abnormalities measurement of BNP plasma values are preferred over ANP plasma values.

Age and blood pressure levels modify the functional properties of central but not peripheral arteries

The effect of age and blood pressure on the carotid and the radial artery distensibilities was investigated. Patients referred to the outpatient clinic of the Department of Internal Medicine and Geriatric Medicine were asked to participate in the study. The carotid and radial artery distensibility coefficients were measured. Linear regression analyses were performed to investigate the associations between determinants and arterial distensibility. The mean age of the participants was 72.3 years, and 41.5% were men. Carotid distensibility decreased with age in adjusted models (beta = -0.317; 95% confidence interval [CI], -0.241, -0.055), whereas the radial distensibility did not decrease. Levels of systolic blood pressure and mean arterial pressure were associated with decreasing levels of carotid distensibility, whereas the diastolic blood pressure and pulse pressure were not associated (beta = -0.571; 95% CI, -0.404, -0.007; beta = -0.410; 95% CI, -0.308, -0.101, respectively). In conclusion, age and blood pressure levels are associated with the distensibility of the central arteries but not with that of the peripheral arteries.

Can echocardiographic findings predict falls in older persons?

Background

The European and American guidelines state the need for echocardiography in patients with syncope. 50% of older adults with syncope present with a fall. Nonetheless, up to now no data have been published addressing echocardiographic abnormalities in older fallers.

Method and Findings

In order to determine the association between echocardiographic abnormalities and falls in older adults, we performed a prospective cohort study, in which 215 new consecutive referrals (age 77.4, SD 6.0) of a geriatric outpatient clinic of a Dutch university hospital were included. During the previous year, 139 had experienced a fall. At baseline, all patients underwent routine two-dimensional and Doppler echocardiography. Falls were recorded during a three-month follow-up. Multivariate adjustment for confounders was performed with a Cox proportional hazards model. 55 patients (26%) fell at least once during follow-up. The adjusted hazard ratio of a fall during follow-up was 1.35 (95% CI, 1.08–1.71) for pulmonary hypertension, 1.66 (95% CI, 1.01 to 2.89) for mitral regurgitation, 2.41 (95% CI, 1.32 to 4.37) for tricuspid regurgitation and 1.76 (95% CI, 1.03 to 3.01) for pulmonary regurgitation. For aortic regurgitation the risk of a fall was also increased, but non-significantly (hazard ratio, 1.57 [95% CI, 0.85 to 2.92]). Trend analysis of the severity of the different regurgitations showed a significant relationship for mitral, tricuspid and pulmonary valve regurgitation and pulmonary hypertension.

Conclusions

Echo(Doppler)cardiography can be useful in order to identify risk indicators for falling. Presence of pulmonary hypertension or regurgitation of mitral, tricuspid or pulmonary valves was associated with a higher fall risk. Our study indicates that the diagnostic work-up for falls in older adults might be improved by adding an echo(Doppler)cardiogram in selected groups.

Remitting seronegative symmetrical synovitis with pitting oedema associated with lung malignancy

RS3PE syndrome is an inflammatory disease which affects mainly males and responds rapidly to low-dose steroids. We describe the concurrence of RS3PE and lung malignancy in a 78-year-old woman. We recommend that an underlying malignancy should always be excluded in patients with RS3PE syndrome, even when general signs and symptoms such as weight loss, anorexia and fever are absent or uncertain.

Withdrawal of fall-risk-increasing drugs in older persons: effect on tilt-table test outcomes

OBJECTIVES

To determine whether outcomes of tilt-table tests improved after withdrawal of fall-risk-increasing drugs (FRIDs).

DESIGN

Prospective cohort study.

SETTING

Geriatric outpatient clinic.

PARTICIPANTS

Two hundred eleven new, consecutive outpatients, recruited from April 2003 until December 2004.

MEASUREMENTS

Tilt-table testing was performed on all participants at baseline. Subsequently, FRIDs were withdrawn in all fallers in whom it was safely possible. At a mean follow-up of 6.7 months, tilt-table testing was repeated in 137 participants. Tilt-table testing addressed carotid sinus hypersensitivity (CSH), orthostatic hypotension (OH), and vasovagal collapse (VVC). Odds ratios (ORs) of tilt-table-test normalization according to withdrawal (discontinuation or dose reduction) of FRIDs were calculated using multivariate logistic regression analysis.

RESULTS

After adjustment for confounders, the reduction of abnormal test outcomes (ORs) according to overall FRID withdrawal was 0.34 (95% confidence interval (CI)=0.06-1.86) for CSH, 0.35 (95% CI=0.13-0.99) for OH, and 0.27 (95% CI=0.02-3.31) for VVC. For the subgroup of cardiovascular FRIDs, the adjusted OR was 0.13 (95% CI=0.03-0.59) for CSH, 0.44 (95% CI=0.18-1.0) for OH, and 0.21 (95% CI=0.03-1.51) for VVC.

CONCLUSION

OH improved significantly after withdrawal of FRIDs. Subgroup analysis of cardiovascular FRID withdrawal showed a significant reduction in OH and CSH. These results imply that FRID withdrawal can cause substantial improvement in cardiovascular homeostasis. Derangement of cardiovascular homeostasis may be an important mechanism by which FRID use results in falls.

Measuring orthostatic hypotension with the Finometer device: is a blood pressure drop of one heartbeat clinically relevant?

OBJECTIVE

The role of orthostatic hypotension in falls in older people is generally accepted. Because of the high degree of intra- and interobserver variability in conventional measurements of orthostatic hypotension, application of continuous measurement systems has been proposed. The clinical relevance of a blood pressure drop lasting one heartbeat, however, is unknown. We therefore investigated which time average of continuous-finger-blood-pressure measurement (Finometer) showed the best association between orthostatic hypotension and falls. This was also compared with conventional sphygmomanometer measurements.

METHODS

In 217 geriatric outpatients supine and standing (finger) blood pressure to diagnose orthostatic hypotension was monitored with Finometry (beat-to-beat and 1, 5, 10, 15, 20 and 30 s averages) and sphygmomanometry. History of fall incidents (previous year) was registered.

RESULTS

The best association (C=0.22, P=0.003) with falls history was found for the 5-s average of Finometry, whereas falls and orthostatic hypotension assessed by sphygmomanometry did not correlate. The odds ratio of a fall according to orthostatic hypotension using the 5-s average was 2.54 (95% CI: 1.37 to 4.71).

CONCLUSIONS

Orthostatic hypotension and falls are correlated when using Finometry, with the best association found when using 5-s averages. As the etiology of falls is often multifactorial, orthostatic hypotension and falls are poorly correlated, irrespective of the method or time average that is applied.

Withdrawal of Fall-Risk-Increasing Drugs in Older Persons

BACKGROUND

Previously, we have shown that withdrawal of fall-risk-increasing drugs (FRIDs) as a single intervention reduces falls incidence. Improvement of mobility may be an important factor in this finding and we therefore tested whether mobility tests improved after FRID withdrawal.

METHODS

In a prospective cohort study of 137 geriatric outpatients (age 77.7 +/- 5.7 years), FRIDs were withdrawn in all fallers, if possible, between April 2003 and November 2004. All patients underwent mobility testing at baseline, including a 10m walking test (WT), Timed 'Up & Go' Test (TUGT), Functional Reach Test (FRT), isometric quadriceps femoris muscle strength and a body sway test. Retesting occurred at a mean follow-up of 6.7 months. The effect of FRID withdrawal (discontinuation or dose reduction) on test outcomes was calculated using both multivariate linear and binary logistic regression analyses.

RESULTS

In the group of fallers with FRID withdrawal all mobility tests improved, as opposed to non-fallers and fallers without FRID withdrawal. After adjustment for confounders, the odds ratio of no improvement was 0.14 (95% CI 0.03, 0.59) for the TUGT, 0.19 (95% CI 0.04, 0.86) for the 10m WT, 0.48 (95% CI 0.14, 1.57) for the FRT, 0.46 (95% CI 0.14, 1.48) for the quadriceps strength test and 0.49 (95% CI 0.15, 1.62) for the body sway test.

CONCLUSION

The results of this study suggest that FRID withdrawal may be effective as a single intervention in a geriatric setting. In addition to reducing falls (as shown in our previous study), FRID withdrawal significantly improved 10m WT and TUGT results over a mean follow-up period of 6.7 months. These tests may therefore be useful tools for monitoring the clinical effect of FRID withdrawal.

Abnormal neurotransmitter metabolite levels in Alzheimer patients with a delirium

BACKGROUND

Delirium is a complex neuropsychiatric syndrome with an acute onset and fluctuating course. Several studies have suggested the presence of disturbed cholinergic, dopaminergic and serotonergic pathways in delirium as well as in Alzheimer's disease. Abnormal concentrations of amino acids and of neurotransmitter metabolites have been found in plasma, platelets and cerebrospinal fluid of AD patients, and in plasma and CSF of patients with a delirium. The aim of this study was to investigate amino acid and neurotransmitter metabolite levels in plasma of AD patients with a concurrent delirium.

METHODS

In a case-control study of patients suffering from Alzheimer's disease (AD) with concurrent delirium, we investigated the contribution of delirium to some biochemical parameters in blood. We compared plasma amino acid and neurotransmitter metabolite levels of 17 delirious AD patients with those of 17 age- and gender-matched non-delirious AD patients and 29 age- and gender-matched controls.

RESULTS

Homovanillic acid (HVA) and 5-hydroxyindoleacetic acid (5-HIAA) levels were higher in delirious AD patients than in controls, but only HVA concentrations were higher in delirious AD patients than in non-delirious AD patients.

CONCLUSIONS

Our findings suggest that central dopaminergic and serotonergic turnover are increased in AD patients with delirium and that the high dopaminergic turnover might reflect the consequences of delirium.

Risk of falls after withdrawal of fall-risk-increasing drugs: a prospective cohort study

AIMS

Falling in older persons is a frequent and serious clinical problem. Several drugs have been associated with increased fall risk. The objective of this study was to identify differences in the incidence of falls after withdrawal (discontinuation or dose reduction) of fall-risk-increasing drugs as a single intervention in older fallers.

METHODS

In a prospective cohort study of geriatric outpatients, we included 139 patients presenting with one or more falls during the previous year. Fall-risk-increasing drugs were withdrawn, if possible. The incidence of falls was assessed within 2 months of follow-up after a set 1 month period of drug withdrawal. Multivariate adjustment for potential confounders was performed with a Cox proportional hazards model.

RESULTS

In 67 patients, we were able to discontinue a fall-risk-increasing drug, and in eight patients to reduce its dose. The total number of fall incidents during follow-up was significantly lower in these 75 patients, than in those who continued treatment (mean number of falls: 0.3 vs. 3.6; P value 0.025). The hazard ratio of a fall during follow-up was 0.48 (95% confidence interval (CI) 0.23, 0.99) for overall drug withdrawal, 0.35 (95% CI 0.15, 0.82) for cardiovascular drug withdrawal and 0.56 (95% CI 0.23, 1.38) for psychotropic drug withdrawal, after adjustment for age, gender, use of fall-risk-increasing drugs, baseline falls frequency, comorbidity, Mini-Mental State Examination score, and reason for referral.

CONCLUSIONS

Withdrawal of fall-risk-increasing drugs appears to be effective as a single intervention for falls prevention in a geriatric outpatient setting. The effect was greatest for withdrawal of cardiovascular drugs.