Improving Drug Prescription in Elderly Diabetic Patients

Nowadays, there is no doubt that there is a good epidemic of ageing with the inversion of the population pyramid. There is no doubt either about the current epidemic of obesity and bad nutritional habits that have resulted in an increase of diabetic patients in the world. And the union of these epidemics has led to an increase of diabetes (DM) in the elderly

The problem of underdosing with direct-acting oral anticoagulants in elderly patients with nonvalvular atrial fibrillation

Unless contraindicated, anticoagulant therapy should be prescribed to elderly patients with atrial fibrillation. Direct-acting oral anticoagulants (DOACs) are superior to vitamin K antagonists for preventing stroke. This, together with their higher net clinical benefit, makes DOACs the treatment of choice in this population. However, due to the concerns about bleeding and the need for dose adjustment based on clinical variables, underdosing of DOACs is common and the risk of stroke high. Drugs with more easily adjusted doses are likely associated with a lower risk of dosing errors and, therefore, a greater protective effect. Correct dosing can ensure a maximal net benefit of DOACs in elderly patients with atrial fibrillation

Design and methodology of the screening for CKD among older patients across Europe (SCOPE) study: a multicenter cohort observational study

Background: Decline of renal function is common in older persons and the prevalence of chronic kidney disease (CKD) is rising with ageing. CKD affects different outcomes relevant to older persons, additionally to morbidity and mortality which makes CKD a relevant health burden in this population. Still, accurate laboratory measurement of kidney function is under debate, since current creatinine-based equations have a certain degree of inaccuracy when used in the older population. The aims of the study are as follows: to assess kidney function in a cohort of 75+ older persons using existing methodologies for CKD screening; to investigate existing and innovative biomarkers of CKD in this cohort, and to align laboratory and biomarker results with medical and functional data obtained from this cohort. The study was registered at ClinicalTrials.gov, identifier NCT02691546, February 25th 2016. Methods/design: An observational, multinational, multicenter, prospective cohort study in community dwelling persons aged 75 years and over, visiting the outpatient clinics of participating institutions. The study will enroll 2450 participants and is carried out in Austria, Germany, Israel, Italy, the Netherlands, Poland and Spain. Participants will undergo clinical and laboratory evaluations at baseline and after 12 and 24 months-follow-up. Clinical evaluation also includes a comprehensive geriatric assessment (CGA). Local laboratory will be used for 'basic' parameters (including serum creatinine and albumin-to-creatinine ratio), whereas biomarker assessment will be conducted centrally. An intermediate telephone follow-up will be carried out at 6 and 18 months. Discussion: Combining the use of CGA and the investigation of novel and existing independent biomarkers within the SCOPE study will help to provide evidence in the development of European guidelines and recommendations in the screening and management of CKD in older people

Oral anticoagulant use and appropriateness in elderly patients with atrial fibrillation in complex clinical conditions: CONVENIENCE study

Non-valvular atrial fibrillation (NVAF) is the most common arrhythmia in older patients. Although direct-acting oral anticoagulants (DOAC) are the antithrombotic treatment of choice, irrespective of age, certain factors may limit their use. The aim of the ACONVENIENCE study was to consult the opinion of a multidisciplinary panel of experts on the appropriateness of using OACs in elderly patients (>75 years) with NVAF associated with certain complex clinical conditions. A consensus project was performed on the basis of a systematic review of the literature, and application of a two-round Delphi survey. The agreement of 79 panellists on 30 Delphi-type statements was evaluated, and their opinion on the appropriateness of different oral anticoagulants in 16 complex clinical scenarios was assessed. A total of 27 consensus statements were agreed upon, including all statements addressing anticoagulation in older patients and in patients at high risk of bleeding complications, and most of those addressing frailty, dementia, risk of falling, and complex cardiac situations. It was almost unanimously agreed upon that advanced age should not influence the anticoagulation decision. Apixaban was the highest-rated therapeutic option in 14/16 situations, followed by edoxaban. There is a high degree of agreement on anticoagulation in older patients with NVAF. Age should not be the single limiting factor when prescribing OACs, and the decision should be made based on net clinical benefit and a comprehensive geriatric assessment. Apixaban, followed by edoxaban, was considered the most appropriate treatment in the various complex clinical situations examined

Multimorbidity as specific disease combinations, an important predictor factor for mortality in octogenarians: the Octabaix study

BACKGROUND: The population is aging and multimorbidity is becoming a common problem in the elderly. OBJECTIVE: To explore the effect of multimorbidity patterns on mortality for all causes at 3- and 5-year follow-up periods. MATERIALS AND METHODS: A prospective community-based cohort (2009-2014) embedded within a randomized clinical trial was conducted in seven primary health care centers, including 328 subjects aged 85 years at baseline. Sociodemographic variables, sensory status, cardiovascular risk factors, comorbidity, and geriatric tests were analyzed. Multimorbidity patterns were defined as combinations of two or three of 16 specific chronic conditions in the same individual. RESULTS: Of the total sample, the median and interquartile range value of conditions was 4 (3-5). The individual morbidities significantly associated with death were chronic obstructive pulmonary disease (COPD; hazard ratio [HR]: 2.47; 95% confidence interval [CI]: 1.3; 4.7), atrial fibrillation (AF; HR: 2.41; 95% CI: 1.3; 4.3), and malignancy (HR: 1.9; 95% CI: 1.0; 3.6) at 3-year follow-up; whereas dementia (HR: 2.04; 95% CI: 1.3; 3.2), malignancy (HR: 1.84; 95% CI: 1.2; 2.8), and COPD (HR: 1.77; 95% CI: 1.1; 2.8) were the most associated with mortality at 5-year follow-up, after adjusting using Barthel functional index (BI). The two multimorbidity patterns most associated with death were AF, chronic kidney disease (CKD), and visual impairment (HR: 4.19; 95% CI: 2.2; 8.2) at 3-year follow-up as well as hypertension, CKD, and malignancy (HR: 3.24; 95% CI: 1.8; 5.8) at 5 years, after adjusting using BI. CONCLUSION: Multimorbidity as specific combinations of chronic conditions showed an effect on mortality, which would be higher than the risk attributable to individual morbidities. The most important predicting pattern for mortality was the combination of AF, CKD, and visual impairment after 3 years. These findings suggest that a new approach is required to target multimorbidity in octogenarians

Multifactorial assessment and targeted intervention in nutritional status among the older adults: a randomized controlled trial: the Octabaix study

Background: Malnutrition is frequent among older people and is associated with morbi-mortality.he aim of the study is to assess the effectiveness of a multifactorial and multidisciplinary intervention in the nutritional status among the elderly. Methods: Randomized, single-blind, parallel-group, clinical trial conducted from January 2009 to December 2010 in seven primary health care centers in Baix Llobregat (Barcelona). Of 696 referred people, born in 1924, 328 subjects were randomized to an intervention group or a control group. The intervention model used an algorithm and was multifaceted for both the patients and their primary care providers. The main outcome was improvement in nutritional status assessed by Mini Nutritional Assessment (MNA). Data analyses were done by intention-to-treat. Results: Two-year assessment was completed for 127 patients (77.4%) in the intervention group and 98 patients (59.7%) in the control group. In the adjusted linear mixed models for MNA, intervention showed no significant effect during all follow-up period with −0.21 (CI: − 0.96; 0.26). In subjects with nutritional risk (MNA ≤ 23.5 / 30) existed a tendency towards improvement in MNA score 1.13 (95% CI −0.48; 2.74) after 2 years. Conclusion: A universal multifactorial assessment and target intervention over a two year period in subjects at nutritional risk showed a tendency to improve nutrition but not in the rest of community-dwelling studied subjects. Cognitive impairment was an independent factor strongly associated with a decline in nutritional status

Evidence of functional declining and global comorbidity measured at baseline proved to be the strongest predictors for long-term death in elderly community residents aged 85 years: a 5-year follow-up evaluation, the OCTABAIX study

Objective: To investigate the predictive value of functional impairment, chronic conditions, and laboratory biomarkers of aging for predicting 5-year mortality in the elderly aged 85 years. Methods: Predictive value for mortality of different geriatric assessments carried out during the OCTABAIX study was evaluated after 5 years of follow-up in 328 subjects aged 85 years. Measurements included assessment of functional status comorbidity, along with laboratory tests on vitamin D, cholesterol, CD4/CD8 ratio, hemoglobin, and serum thyrotropin. Results: Overall, the mortality rate after 5 years of follow-up was 42.07%. Bivariate analysis showed that patients who survived were predominantly female (P=0.02), and they showed a significantly better baseline functional status for both basic (P<0.001) and instrumental (P<0.001) activities of daily living (Barthel and Lawton index), better cognitive performance (Spanish version of the Mini-Mental State Examination) (P<0.001), lower comorbidity conditions (Charlson) (P<0.001), lower nutritional risk (Mini Nutritional Assessment) (P<0.001), lower risk of falls (Tinetti gait scale) (P<0.001), less percentage of heart failure (P=0.03) and chronic obstructive pulmonary disease (P=0.03), and took less chronic prescription drugs (P=0.002) than nonsurvivors. Multivariate Cox regression analysis identified a decreased score in the Lawton index (hazard ratio 0.86, 95% confidence interval: 0.78-0.91) and higher comorbidity conditions (hazard ratio 1.20, 95% confidence interval: 1.08-1.33) as independent predictors of mortality at 5 years in the studied population. Conclusion: The ability to perform instrumental activities of daily living and the global comorbidity assessed at baseline were the predictors of death, identified in our 85-year-old community-dwelling subjects after 5 years of follow-up

Functional And Cognitive Decline Is Associated With Increased Endothelial Cell Inflammation And Platelet Activation. Liquid Biopsy Of Microvesicles In Community-Dwelling Octogenarians.

Increased life expectancy is usually associated with comorbidities, such as cardio andcerebrovascular disease causing impaired functionality. A common underlying cause ofthese comorbidities is vascular inflammation and injury. Elevated levels of circulatingmicrovesicles (cMV), as a product of a hemostatic and inflammatory cell activation,could be direct mapping of an imbalanced hemostasis. In this manuscript, we aimedto investigate by liquid biopsy whether successful aging can be discriminated bycMV levels and phenotype. To this purpose, we included 135 community-dwellingoctogenarians in a cross-sectional study. Successful aging was defined as goodfunctional (Barthel Index>90 points, and Lawton index score>7/4 points forwomen and men, respectively) and cognitive status (Spanish version of the Mini-Mental State Examination -MEC->24 points) and no need for institutionalization.Total, annexin V positive (AV+), and AV−cMV from different cell origins from thevascular compartment were phenotypically characterized and quantified from fastingplasma samples by flow cytometry. Successful aging was associated with lowerplasma concentrations of total and AV+CD141+/CD41+-CD61+, and PAC1+/AV+,CD141+/AV+, and CD36+/AV−cMV. From these phenotypes, ROC curve analysesrevealed that CD141+/AV+and CD141+/CD41+-CD61+/AV+endothelial- and platelet-derived cMV discriminate successful and non-successful aging with an AUC (95%CI) of0.655 (0.551, 0.758),P= 0.005, and 0.638 (0.535, 0.741),P= 0.013, respectively. In conclusion, successful aging is associated with low levels of cMV released by endothelialcells and platelets, indicating lower endothelial cell inflammation and platelet activation.Our results contribute to the understanding of the link between unsuccessful aging,cognitive decline and vascular cell inflammatory disturbances

Low co-morbidity, low levels of malnutrition, and low risk of falls in a community-dwelling sample of 85-year-old are associated with succesful aging: the Octabaix study

The population is aging throughout the world. Preserving physical and cognitive functions is crucial to successful aging. The aim of this study was to determine the proportion of 85-year-old community-dwelling subjects aging successfully, applying a quantitative approach, and assessing the association of successful aging with sociodemographic data, global geriatric assessment, and co-morbidity. This was a community-based survey of inhabitants aged 85 years, with 328 out of 487 subjects born in 1924 assigned to seven primary health-care teams, representing a participation rate of 67.5%. Sociodemographic variables, Barthel index (BI), the Spanish version of the Mini-Mental State Examination (MEC), Mini Nutritional Assessment (MNA), Charlson Index, Gait Rating Scale, social risk, quality of life (QoL), and prevalent chronic diseases were assessed. Subjects scoring higher than 90 on the BI and higher than 24 on the MEC were compared with the rest. Multiple regression analysis was performed. Using these criteria, successful aging status was defined in 162 (49.3%) subjects. Using multiple logistic regression analysis, successful agers had significantly lower co-morbidity scores (p 0.0001). Almost half of the individuals presented successful aging. Successful agers had less co-morbidity and a lower risk of falls or malnutrition, and they had higher scores on the QoL scale

Utility of geriatric assessment to predict mortality in the oldest old: the Octabaix Study 3-year follow-up

Objective: Few studies have prospectively evaluated the utility of geriatric assessment tools as predictors of mortality in the oldest population. We investigated predictors of death in an oldest-old cohort after 3 years of follow-up. Methods: The Octabaix study is a prospective, community-based study with a follow-up period of 3 years involving 328 subjects aged 85 at baseline. Data were collected on functional and cognitive status, co-morbidity, nutritional and falls risk, quality of life, social risk, and long-term drug prescription. Vital status for the total cohort was evaluated after 3 years of follow-up. Results: Mortality after 3 years was 17.3%. Patients who did not survive had significantly poorer baseline functional status for basic and instrumental activities of daily living (Barthel and Lawton Index), higher co-morbidity (Charlson), higher nutritional risk (Mini Nutritional Assessment), higher risk of falls (Tinetti Gait Scale), poor quality of life (visual analog scale of the Quality of Life Test), and higher number of chronic drugs prescribed. Cox regression analysis identified the Lawton Index (hazard ratio [HR] 0.82, 95% confidence interval [CI] 0.73-0.89) and the number of chronic drugs prescribed (HR 1.09, 95% CI 1.01-1.18) as independent predictors of mortality at 3 years. Conclusions: Among the variables studied, the ability to perform instrumental activities of daily living and using few drugs on a chronic basis at baseline are the best predictors of which oldest-old community-dwelling subjects survive after a 3-year follow-up period