Relation of Statin Use and Mortality in Community-Dwelling Frail Older Patients With Coronary Artery Disease

Clinical decision-making for statin treatment in older patients with coronary artery disease (CAD) is under debate, particularly in community-dwelling frail patients at high risk of death. In this retrospective observational study on 2,597 community-dwelling patients aged >= 65 years with a previous hospitalization for CAD, we estimated mortality risk assessed with the Multidimensional Prognostic Index (MPI), based on the Standardized Multidimensional Assessment Schedule for Adults and Aged Persons (SVaMA), used to determine accessibility to homecare services/nursing home admission in 2005 to 2013 in the Padua Health District, Veneto, Italy. Participants were categorized as having mild (MPI-SVaMA-1), moderate (MPI-SVaMA-2), and high (MPI-SVaMA-3) baseline mortality risk, and propensity score-adjusted hazard ratios (HRs) of 3-year mortality rate were calculated according to statin treatment in these subgroups. Greater MPI-SVaMA scores were associated with lower rates of statin treatment and higher 3-year mortality rate (MPI-SVaMA-1 = 23.4%; MPI-SVaMA-2 = 39.1%; MPI-SVaMA-3 = 76.2%). After adjusting for propensity score quintiles, statin treatment was associated with lower 3-year mortality risk irrespective of MPI-SVaMA group (HRs [95% confidence intervals] 0.45 [0.37 to 0.55], 0.44 [0.36 to 0.53], and 0.28 [0.21 to 0.39] in MPI-SVaMA-1,-2, and-3 groups, respectively [interaction test p = 0.202]). Subgroup analyses showed that statin treatment was also beneficial irrespective of age (HRs [95% confidence intervals] 0.38 [0.27 to 0.53], 0.45 [0.38 to 0.54], and 0.44 [0.37 to 0.54] in 65 to 74, 75 to 84, and Z85 year age groups, respectively [interaction test p = 0.597]). In conclusion, in community-dwelling frail older patients with CAD, statin treatment was significantly associated with reduced 3-year mortality rate irrespective of age and multidimensional impairment, although the frailest patients were less likely to be treated with statins. (C) 2016 Elsevier Inc. All rights reserved.Peer reviewe

Statin treatment and mortality in community-dwelling frail older patients with diabetes mellitus

Background: Older adults are often excluded from clinical trials. Decision making for administration of statins to older patients with diabetes mellitus (DM) is under debate, particularly in frail older patients with comorbidity and high mortality risk. We tested the hypothesis that statin treatment in older patients with DM was differentially effective across strata of mortality risk assessed by the Multidimensional Prognostic Index (MPI), based on information collected with the Standardized Multidimensional Assessment Schedule for Adults and Aged Persons (SVaMA). Methods: In this retrospective observational study, we estimated the mortality risk in 1712 community-dwelling subjects with DM ≥ 65 years who underwent a SVaMA evaluation to establish accessibility to homecare services/nursing home admission from 2005 to 2013 in the Padova Health District, Italy. Mild (MPI-SVaMA-1), moderate (MPI-SVaMA-2), and high (MPI-SVaMA-3) risk of mortality at baseline and propensity score-adjusted hazard ratios (HR) of three-year mortality were calculated according to statin treatment. Results: Higher MPI-SVaMA scores were associated with lower rates of statin treatment (MPI-SVaMA-1 = 39% vs MPI-SVaMA-2 = 36% vs MPI-SVaMA-3 = 24.9%. p<0.001) and higher three-year mortality (MPI-SVaMA-1 = 12.9% vs MPI-SVaMA-2 = 24% vs MPI-SVaMA-3 = 34.4%, p<0.001). After adjustment for propensity score quintiles, statin treatment was significantly associated with lower three-year mortality irrespective of MPI-SVaMA group (interaction test p = 0.303). HRs [95% confidence interval (CI)] were 0.19 (0.14-0.27), 0.28 (0.21-0.36), and 0.26 (0.20-0.34) in the MPI-SVaMA-1, MPI-SVaMA-2, and MPI-SVaMA-3 groups, respectively. Subgroup analyses showed that statin treatment was also beneficial irrespective of age. HRs (95% CI) were 0.21 (0.15-0.31), 0.26 (0.20-0.33), and 0.26 (0.20-0.35) among patients aged 65-74, 75-84, and ≥ 85 years, respectively (interaction test p=0.812). Conclusions: Statin treatment was significantly associat

Gender differences in therapies and outcome in cardiovascular disease

The purpose of this analysis was to explore, by using an administrative database, gender and age differences in drug prescriptions of ordinarily residents, entitled to either free or subsidised approved prescribed drugs and medicines and and surgical interventions provided from the Local Health Service. Further analysis was performed in the cohort of patients that experienced an ACS during 2008. Methods: All residents of the Local Health Service Area 16 of the Veneto Region (Italy) ages 15-44, 45-64, 65-79 and >=80 years in the period 1st of January until 31st of December 2010, were included in the study. The Local Health Service system, covering this area, keeps record of all drug prescriptions dispensed by public or private pharmacies. All medications dispensed during 2010 were considered and classified according to Anatomical Therapeutic Chemical (ATC) classification system. Results were reported as odds ratios (OR) of prescriptions dispensed to males and females with 95% confidence intervals (CI) to analyse the number of subjects that received at least one medication. A detailed analysis was conducted for Cardiovascular drugs (ATC: C) in the cohort of 1,204 ACS patients (760 men and 444 women) being admitted in Saint’Anthony Hospital. Data of therapies and interventions were collected from the hospital and local medical distribution database. Results: Of the 491,261 included subjects, 255,026 were females and 236,235 males. Females were medicine dispensed in most of ATC subgroups as with antiulcer drugs (OR=0.80, 95% confidence interval [CI] 0.74-0.86), antibiotics(39% M vs. 46% F, p<0.001) as for tetracyclines (OR=0.91 95% CI 0.85-0.93), penicillins (OR=0.90 in the 95% CI 0.83-0.94), antimigraine preparations (OR 0.34 95% CI 0.0.31-0.36), antipsychotics (OR=0.86, 95% CI 0.81-0.90), antidepressants (3.74%M vs. 8.09% F, OR=0.44, 95% CI 0.40-0.52) diuretics (OR=0.72, 95% CI 0.66-0.80). On the other hand, males were dispensed more with antidiabetic drugs, insulin therapy (OR= 1.24 95% CI 1.21-1.30) and with oral hypoglycaemic (OR=1.37 95% CI 1.33-1.40), more exposed to treatment for cardiovascular disease with antithrombotic agents (12.11% M vs. 11.33%F, OR=1.16 95% CI 1.14-1.20), betablockers (OR=1.15 95% CI 1.10-1.20), ACE-inhibitors (OR=1.25 95% CI 1.20-1.30). Males were generally more prescribed with cardiovascular medications than their female counterparts. An obvious gender difference in drug utilisation was noticed during the 15-44 years of age, this difference decreased with aging, but still the medication use difference remained statistically significant. The prevalence of ACS was 2.5 ‰ (3.26‰ in male patients and 0.92‰ in female patients, OR=1.7 95% CI 1.4-2.0). Of the ACS patients, 142 (11.8%) died in hospital without any gender and age difference. Thus, for further investigations a cohort of 1,062 ACS patients (688 male and 374 female patients) was considered. Of these patients 40.12% underwent a revascularization intervention and 48.1% were not revascularised. Male patients over 65 years of age (73.4%) were significantly more likely to have a revascularization than the female patients (26.6%) of the same age (age group: 65-79, OR=1.7 95%CI 1.2-2.5; age group >=80, OR=4.1 95%CI 2.2-7.6). Six months after hospital discharge antiaggregation therapy was analysed. In the ACS population 82% received at least one antiaggregant. The remaining population 18% did not receive any antiaggregant at all, generally those were female patients (OR=2.8 95%CI 2.1-3.8). Aspirin was used in 35% of the non- revascularized vs. 28 % of the revascularized patient especially in non-revascularized female patients; Thienopyridines were dispensed in 8% of the non-revascularized vs. 5% of the revascularized patients especially in revascularized female patients, dual antiplateletes therapy was more dispensed in revascularized patients (61% vs. 29%), especially in male non-revascularized patients. For the other non mentioned therapies male and female patients were treated equally. Regarding to therapy adherence, male patients were in general more adherent to Aspirin (92%M vs. 82%F, OR=2.4 95%CI 1.2-4.6) on the other hand, to Thienopyridines (87%M vs. 84%F, OR=1.3 95%CI 0.3-5.0) and to Dual-antiplateletes therapy (76%M vs.74%F, OR=1.1 95%CI 0.7-1.8) both male and female patients were adherent without gender differences. Conclusions: As women are more exposed to chronic and acute conditions, especially in the reproductive years 15 to 44 and in pre- and post-menopausal age, according to the literature, our results support the suggestion that females are dispensed more medicines than males in general. On the contrary, men were more exposed to cardiovascular drugs than women. ACS occured more frequently in men than in women. In general men were more revascularized than women. On discharge, female patients were not usually treated with antiaggregant therapy, more often than their male counterparts. Revascularized patients compared to non-revascularized patients did not have any gender difference in terms of therapy, but an evaluation between non-revascularized patients indicated an inequity between male-female patients use of antiaggregants. On the whole, both female and male ACS patients were adherent to therapy. In general, men had a better survival than womenL’obbiettivo iniziale della ricerca è stato quello di descrivere la storia prescrittiva di tutti i farmaci nell’anno 2010. Tramite l’analisi dei dati di prescrizione provenienti dall’Assistenza Farmaceutica Territoriale di Padova è stato possibile descrivere l’utilizzo di questi farmaci nella popolazione generale. Sono risultati maggiormente utilizzati: gli antibiotici (con 39% M vs 46 % F con almeno un antibiotico prescritto, p<0,001), gli antiulcera( 13,20% M vs 16,68 % F, p<0,001), gli antireumatici (10,84% M vs 16,70 % F, p<0,001), gli antidepressivi (con 3,74% M vs 8,09 % F, p<0,001) etc., con una prevalenza di trattati del genere femminile. Una prevalenza di trattati del genere maschile è stata osservata invece per gli antitrombotici (con 12,11% M vs 11,33% F, p<0,025), gli antidiabetici di cui insulino-trattati 1,26% M vs 1,03 % F, p<0,05 ed i trattati con ipoglicemizzanti 3,73% M vs 2,83 % F, p<0,05) ed i dislipidemici (8,93%M vs 8,08%F, p<0,025) etc. Tutti questi dati riportati sono statisticamente significativi. Questa analisi indica anche che il genere femminile è in assoluto il maggior consumatore di farmaci antidolorifici, risultato che porta a dedurre che le donne soffrono maggiormente di dolore acuto e cronico, ma può essere anche un indicatore di una maggiore propensione della donna alla ricerca di una visita medica rispetto all’uomo, il quale forse preferisce rimedi autogestibili (OTC oppure a fumo e alcool). L’alto numero di donne fra i trattati con farmaci del sistema nervoso (antipsicotici, antidepressivi) fa pensare a questi “giorni moderni” in cui la donna è ancora vittima di violenza non solo fisica, ma anche psichica, e si trova spesso sottoposta a stress, come risultato dell’emancipazione. La moglie-madre-donna in carriera è esposta ad una vita frenetica e le tante responsabilità accumulate negli anni tendono a portarla alla parità col genere maschile. Una analisi più approfondita è stata fatta nello specifico per i farmaci cardiovascolari. La maggior parte dei farmaci cardiovascolari è stato dispensato prevalentemente al genere maschile, ma bisogna sottolineare che le malattie cardiovascolari erano la causa principale di morte in entrambi i sessi. Non si è verificata alcuna differenza di genere nella prevalenza di trattati per i sottogruppi dei betabloccanti non associati, calcio antagonisti con effetto cardio-diretto e antagonisti dell’angiotensina II, mentre per gli antitrombotici, gli antiaritmici di classe sia I che III, gli ipocolesterolemizzanti e ipotrigliceridemizzanti si è osservato un utilizzo maggiore nel genere maschile. Per quanto riguarda le malattie trombotiche, le femmine risultavano meno trattate dei maschi, in accordo con il fatto che il maschio adulto, a parità di età, è più propenso alla trombosi rispetto alla femmina adulta, perché con l’avanzare dell’età ha una maggiore aggregazione piastrinica rispetto alla femmina. Infine, l’attenzione è stata focalizzata sull’evento della sindrome coronarica acuta (SCA) per analizzare la presenza di eventuali differenze di genere in pazienti ospedalizzati per SCA in relazione ai seguenti indicatori: prevalenza di ricoveri per SCA, mortalità intra- ed extra-ospedaliera, tipologia di interventi di rivascolarizzazione, trattamento farmacologico alla dimissione, aderenza alla terapia e sopravivvenza. Nel corso dell’anno 2008, sono stati ricoverati per SCA 1.204 pazienti (760 maschi e 444 femmine). La prevalenza dei ricoveri è stata significativamente superiore negli uomini (3,26‰ ) rispetto alle donne (0,92‰) con OR = 1,7 (IC 95% = 1,4-2,0). Dei 1.204 pazienti arruolati 142, ovvero 11,8%, sono andati incontro a decesso intraospedaliero. Sono state analizzate le recidive a breve e lungo termine. Le donne in entrambi i casi andavano in contro a recidive più frequentemente degli uomini (nel 2009 il 17,9% delle donne vs. 12,6% degli uomini e nel 2012 32% donne vs. 24% degli uomini, p<0,05). Una fotografia della terapia nei 12 mesi precedenti l’evento evidenziava un trattamento con antiipertensivi e antidepressivi maggiore nelle donne. Per quanto riguarda il trattamento del diabete e delle dislipidemie non si evidenzia nessuna differenza di genere nell’utilizzo dei farmaci riguardanti queste patologie. E‘ stata fatta una analisi degli interventi di rivascolarizzazione per rilevare eventuali differenze di genere e differenze di età. Il 40,12% della popolazione è andata incontro a rivascolarizzazione invece il 48,1% non è stata rivascolarizzata. Nella fascia di età 65-79 anni il 73,4% dei maschi ha subito un intervento di rivascolarizzazione contro il 26,6% delle donne (OR=1,7 con IC 95% =1,2-2,5). Negli over 80, gli uomini sono sempre maggiormente rivascolarizzati (71,2%M vs 28,8F OR= 4,1 con IC 95% = 2,2-7,6). Questi dati hanno confermato che in generale gli uomini vengono sottoposti a questo tipo di interventi più delle donne. Per quanto riguarda l'aderenza alla terapia, i pazienti di sesso maschile sono stati più aderenti alla terapia limitatamente all’aspirina (92% M vs 82% F, OR = 2,4 IC 95% 1,2-4,6). L'analisi di sopravvivenza ha mostrato una prognosi migliore del genere maschile, con una mortalità più alta del genere femminil

Gender differences in therapies and outcome in cardiovascular disease

The purpose of this analysis was to explore, by using an administrative database, gender and age differences in drug prescriptions of ordinarily residents, entitled to either free or subsidised approved prescribed drugs and medicines and and surgical interventions provided from the Local Health Service. Further analysis was performed in the cohort of patients that experienced an ACS during 2008. Methods: All residents of the Local Health Service Area 16 of the Veneto Region (Italy) ages 15-44, 45-64, 65-79 and >=80 years in the period 1st of January until 31st of December 2010, were included in the study. The Local Health Service system, covering this area, keeps record of all drug prescriptions dispensed by public or private pharmacies. All medications dispensed during 2010 were considered and classified according to Anatomical Therapeutic Chemical (ATC) classification system. Results were reported as odds ratios (OR) of prescriptions dispensed to males and females with 95% confidence intervals (CI) to analyse the number of subjects that received at least one medication. A detailed analysis was conducted for Cardiovascular drugs (ATC: C) in the cohort of 1,204 ACS patients (760 men and 444 women) being admitted in Saint’Anthony Hospital. Data of therapies and interventions were collected from the hospital and local medical distribution database. Results: Of the 491,261 included subjects, 255,026 were females and 236,235 males. Females were medicine dispensed in most of ATC subgroups as with antiulcer drugs (OR=0.80, 95% confidence interval [CI] 0.74-0.86), antibiotics(39% M vs. 46% F, p<0.001) as for tetracyclines (OR=0.91 95% CI 0.85-0.93), penicillins (OR=0.90 in the 95% CI 0.83-0.94), antimigraine preparations (OR 0.34 95% CI 0.0.31-0.36), antipsychotics (OR=0.86, 95% CI 0.81-0.90), antidepressants (3.74%M vs. 8.09% F, OR=0.44, 95% CI 0.40-0.52) diuretics (OR=0.72, 95% CI 0.66-0.80). On the other hand, males were dispensed more with antidiabetic drugs, insulin therapy (OR= 1.24 95% CI 1.21-1.30) and with oral hypoglycaemic (OR=1.37 95% CI 1.33-1.40), more exposed to treatment for cardiovascular disease with antithrombotic agents (12.11% M vs. 11.33%F, OR=1.16 95% CI 1.14-1.20), betablockers (OR=1.15 95% CI 1.10-1.20), ACE-inhibitors (OR=1.25 95% CI 1.20-1.30). Males were generally more prescribed with cardiovascular medications than their female counterparts. An obvious gender difference in drug utilisation was noticed during the 15-44 years of age, this difference decreased with aging, but still the medication use difference remained statistically significant. The prevalence of ACS was 2.5 ‰ (3.26‰ in male patients and 0.92‰ in female patients, OR=1.7 95% CI 1.4-2.0). Of the ACS patients, 142 (11.8%) died in hospital without any gender and age difference. Thus, for further investigations a cohort of 1,062 ACS patients (688 male and 374 female patients) was considered. Of these patients 40.12% underwent a revascularization intervention and 48.1% were not revascularised. Male patients over 65 years of age (73.4%) were significantly more likely to have a revascularization than the female patients (26.6%) of the same age (age group: 65-79, OR=1.7 95%CI 1.2-2.5; age group >=80, OR=4.1 95%CI 2.2-7.6). Six months after hospital discharge antiaggregation therapy was analysed. In the ACS population 82% received at least one antiaggregant. The remaining population 18% did not receive any antiaggregant at all, generally those were female patients (OR=2.8 95%CI 2.1-3.8). Aspirin was used in 35% of the non- revascularized vs. 28 % of the revascularized patient especially in non-revascularized female patients; Thienopyridines were dispensed in 8% of the non-revascularized vs. 5% of the revascularized patients especially in revascularized female patients, dual antiplateletes therapy was more dispensed in revascularized patients (61% vs. 29%), especially in male non-revascularized patients. For the other non mentioned therapies male and female patients were treated equally. Regarding to therapy adherence, male patients were in general more adherent to Aspirin (92%M vs. 82%F, OR=2.4 95%CI 1.2-4.6) on the other hand, to Thienopyridines (87%M vs. 84%F, OR=1.3 95%CI 0.3-5.0) and to Dual-antiplateletes therapy (76%M vs.74%F, OR=1.1 95%CI 0.7-1.8) both male and female patients were adherent without gender differences. Conclusions: As women are more exposed to chronic and acute conditions, especially in the reproductive years 15 to 44 and in pre- and post-menopausal age, according to the literature, our results support the suggestion that females are dispensed more medicines than males in general. On the contrary, men were more exposed to cardiovascular drugs than women. ACS occured more frequently in men than in women. In general men were more revascularized than women. On discharge, female patients were not usually treated with antiaggregant therapy, more often than their male counterparts. Revascularized patients compared to non-revascularized patients did not have any gender difference in terms of therapy, but an evaluation between non-revascularized patients indicated an inequity between male-female patients use of antiaggregants. On the whole, both female and male ACS patients were adherent to therapy. In general, men had a better survival than womenL’obbiettivo iniziale della ricerca è stato quello di descrivere la storia prescrittiva di tutti i farmaci nell’anno 2010. Tramite l’analisi dei dati di prescrizione provenienti dall’Assistenza Farmaceutica Territoriale di Padova è stato possibile descrivere l’utilizzo di questi farmaci nella popolazione generale. Sono risultati maggiormente utilizzati: gli antibiotici (con 39% M vs 46 % F con almeno un antibiotico prescritto, p<0,001), gli antiulcera( 13,20% M vs 16,68 % F, p<0,001), gli antireumatici (10,84% M vs 16,70 % F, p<0,001), gli antidepressivi (con 3,74% M vs 8,09 % F, p<0,001) etc., con una prevalenza di trattati del genere femminile. Una prevalenza di trattati del genere maschile è stata osservata invece per gli antitrombotici (con 12,11% M vs 11,33% F, p<0,025), gli antidiabetici di cui insulino-trattati 1,26% M vs 1,03 % F, p<0,05 ed i trattati con ipoglicemizzanti 3,73% M vs 2,83 % F, p<0,05) ed i dislipidemici (8,93%M vs 8,08%F, p<0,025) etc. Tutti questi dati riportati sono statisticamente significativi. Questa analisi indica anche che il genere femminile è in assoluto il maggior consumatore di farmaci antidolorifici, risultato che porta a dedurre che le donne soffrono maggiormente di dolore acuto e cronico, ma può essere anche un indicatore di una maggiore propensione della donna alla ricerca di una visita medica rispetto all’uomo, il quale forse preferisce rimedi autogestibili (OTC oppure a fumo e alcool). L’alto numero di donne fra i trattati con farmaci del sistema nervoso (antipsicotici, antidepressivi) fa pensare a questi “giorni moderni” in cui la donna è ancora vittima di violenza non solo fisica, ma anche psichica, e si trova spesso sottoposta a stress, come risultato dell’emancipazione. La moglie-madre-donna in carriera è esposta ad una vita frenetica e le tante responsabilità accumulate negli anni tendono a portarla alla parità col genere maschile. Una analisi più approfondita è stata fatta nello specifico per i farmaci cardiovascolari. La maggior parte dei farmaci cardiovascolari è stato dispensato prevalentemente al genere maschile, ma bisogna sottolineare che le malattie cardiovascolari erano la causa principale di morte in entrambi i sessi. Non si è verificata alcuna differenza di genere nella prevalenza di trattati per i sottogruppi dei betabloccanti non associati, calcio antagonisti con effetto cardio-diretto e antagonisti dell’angiotensina II, mentre per gli antitrombotici, gli antiaritmici di classe sia I che III, gli ipocolesterolemizzanti e ipotrigliceridemizzanti si è osservato un utilizzo maggiore nel genere maschile. Per quanto riguarda le malattie trombotiche, le femmine risultavano meno trattate dei maschi, in accordo con il fatto che il maschio adulto, a parità di età, è più propenso alla trombosi rispetto alla femmina adulta, perché con l’avanzare dell’età ha una maggiore aggregazione piastrinica rispetto alla femmina. Infine, l’attenzione è stata focalizzata sull’evento della sindrome coronarica acuta (SCA) per analizzare la presenza di eventuali differenze di genere in pazienti ospedalizzati per SCA in relazione ai seguenti indicatori: prevalenza di ricoveri per SCA, mortalità intra- ed extra-ospedaliera, tipologia di interventi di rivascolarizzazione, trattamento farmacologico alla dimissione, aderenza alla terapia e sopravivvenza. Nel corso dell’anno 2008, sono stati ricoverati per SCA 1.204 pazienti (760 maschi e 444 femmine). La prevalenza dei ricoveri è stata significativamente superiore negli uomini (3,26‰ ) rispetto alle donne (0,92‰) con OR = 1,7 (IC 95% = 1,4-2,0). Dei 1.204 pazienti arruolati 142, ovvero 11,8%, sono andati incontro a decesso intraospedaliero. Sono state analizzate le recidive a breve e lungo termine. Le donne in entrambi i casi andavano in contro a recidive più frequentemente degli uomini (nel 2009 il 17,9% delle donne vs. 12,6% degli uomini e nel 2012 32% donne vs. 24% degli uomini, p<0,05). Una fotografia della terapia nei 12 mesi precedenti l’evento evidenziava un trattamento con antiipertensivi e antidepressivi maggiore nelle donne. Per quanto riguarda il trattamento del diabete e delle dislipidemie non si evidenzia nessuna differenza di genere nell’utilizzo dei farmaci riguardanti queste patologie. E‘ stata fatta una analisi degli interventi di rivascolarizzazione per rilevare eventuali differenze di genere e differenze di età. Il 40,12% della popolazione è andata incontro a rivascolarizzazione invece il 48,1% non è stata rivascolarizzata. Nella fascia di età 65-79 anni il 73,4% dei maschi ha subito un intervento di rivascolarizzazione contro il 26,6% delle donne (OR=1,7 con IC 95% =1,2-2,5). Negli over 80, gli uomini sono sempre maggiormente rivascolarizzati (71,2%M vs 28,8F OR= 4,1 con IC 95% = 2,2-7,6). Questi dati hanno confermato che in generale gli uomini vengono sottoposti a questo tipo di interventi più delle donne. Per quanto riguarda l'aderenza alla terapia, i pazienti di sesso maschile sono stati più aderenti alla terapia limitatamente all’aspirina (92% M vs 82% F, OR = 2,4 IC 95% 1,2-4,6). L'analisi di sopravvivenza ha mostrato una prognosi migliore del genere maschile, con una mortalità più alta del genere femminil

Perspective: the challenge of clinical decision-making for drug treatment in older people. The role of multidimensional assessment and prognosis

A complex decision path with a careful evaluation of the risk-benefit ratio is mandatory for drug treatment in advanced age. Enrollment biases in randomized clinical trials (RCTs) cause an under-representation of older individuals. In high-risk frail older subjects, the lack of RCTs makes clinical decision-making particularly difficult. Frail individuals are markedly susceptible to adverse drug reactions, and frailty may result in reduced treatment efficacy. Life expectancy should be included in clinical decision-making paths to better assess the benefits and risks of different drug treatments in advanced age. We performed a scoping review of principal hospital- and community-based prognostic indices in older age. Mortality prognostic tools could help clinical decision-making in diagnostics and therapeutics, tailoring appropriate intervention for older patients. The effectiveness of drug treatments may be significantly different in older patients with different risk of mortality. Clinicians need to consider the prognostic information obtained through well-validated, accurate, and calibrated predictive tools to identify those patients who may benefit from drug treatments given with the aim of increasing survival

Gastrointestinal Microbiota and Their Contribution to Healthy Aging

Studies on populations at different ages have shown that after birth, the gastrointestinal (GI) microbiota composition keeps evolving, and this seems to occur especially in old age. Significant changes in GI microbiota composition in older subjects have been reported in relation to diet, drug use and the settings where the older subjects are living, that is, in community nursing homes or in a hospital. Moreover, changes in microbiota composition in the old age have been related to immunosenescence and inflammatory processes that are pathophysiological mechanisms involved in the pathways of frailty. Frailty is an age-related condition of increased vulnerability to stresses due to the impairment in multiple inter-related physiologic systems that are associated with an increased risk of adverse outcomes, such as falls, delirium, institutionalization, hospitalization and death. Preliminary data suggest that changes in microbiota composition may contribute to the variations in the biological, clinical, functional and psycho-social domains that occur in the frail older subjects. Multidimensional evaluation tools based on a Comprehensive Geriatric Assessment (CGA) have demonstrated to be useful in identifying and measuring the severity of frailty in older subjects. Thus, a CGA approach should be used more widely in clinical practice to evaluate the multidimensional effects potentially related to GI microbiota composition of the older subjects. Probiotics have been shown to be effective in restoring the microbiota changes of older subjects, promoting different aspects of health in elderly people as improving immune function and reducing inflammation. Whether modulation of GI microbiota composition, with multi-targeted interventions, could have an effect on the prevention of frailty remains to be further investigated in the perspective of improving the health status of frail ‘high risk' older individuals.</jats:p