Birkan Ilhan

The role of rheumatoid arthritis (RA) flare and cumulative burden of RA severity in the risk of cardiovascular disease

Objective To examine the role of rheumatoid arthritis (RA) flare, remission and RA severity burden in cardiovascular disease (CVD). Methods In a population-based cohort of patients with RA without CVD (age ≥30 years; 1987 American College of Rheumatology criteria met in 1988–2007), we performed medical record review at each clinical visit to estimate flare/remission status. The previously validated RA medical Records-Based Index of Severity (RARBIS) and Claims-Based Index of RA Severity (CIRAS) were applied. Age- and sex-matched non-RA subjects without CVD comprised the comparison cohort. Cox models were used to assess the association of RA activity/severity with CVD, adjusting for age, sex, calendar year of RA, CVD risk factors and antirheumatic medications. Results Study included 525 patients with RA and 524 non-RA subjects. There was a significant increase in CVD risk in RA per time spent in each acute flare versus remission (HR 1.07 per 6-week flare, 95% CI 1.01 to 1.15). The CVD risk for patients with RA in remission was similar to the non-RA subjects (HR 0.90, 95% CI 0.51 to 1.59). Increased cumulative moving average of daily RARBIS (HR 1.16, 95% CI 1.03 to 1.30) and CIRAS (HR 1.38, 95% CI 1.12 to 1.70) was associated with CVD. CVD risk was higher in patients with RA who spent more time in medium (HR 1.08, 95% CI 0.98 to 1.20) and high CIRAS tertiles (HR 1.18, 95% CI 1.06 to 1.31) versus lower tertile. Conclusions Our findings show substantial detrimental role of exposure to RA flare and cumulative burden of RA disease severity in CVD risk in RA, suggesting important cardiovascular benefits associated with tight inflammation control and improved flare management in patients with RA.

Routine deprescribing of chronic medications to combat polypharmacy

The positive benefit–risk ratio of most drugs is decreasing in correlation to very old age, the extent of comorbidity, dementia, frailty and limited life expectancy (VOCODFLEX). First, we review the extent of inappropriate medication use and polypharmacy (IMUP) globally and highlight its negative medical, nursing, social and economic consequences. Second, we expose the main clinical/practical and perceptual obstacles that combine to create the negative vicious circle that eventually makes us feel frustrated and hopeless in treating VOCODFLEX in general, and in our ‘war against IMUP’ in particular. Third, we summarize the main international approaches/methods suggested and tried in different countries in an attempt to improve the ominous clinical and economic outcomes of IMUP; these include a variety of clinical, pharmacological, computer-assisted and educational programs. Lastly, we suggest a new comprehensive perception for providing good medical practice to VOCODFLEX in the 21st century. This includes new principles for research, education and clinical practice guidelines completely different from the ‘single disease model’ research and clinical rules we were raised upon and somehow ‘fanatically’ adopted in the 20th century. This new perception, based on palliative, geriatric and ethical principle, may provide fresh tools for treating VOCODFLEX in general and reducing IMUP in particular.

Low glomerular filtration rate as an associated risk factor for sarcopenic muscle strength: is creatinine or cystatin C-based estimation more relevant?

Abstract Introduction: We aimed to evaluate the association of a decreased glomerular-filtration-rate (GFR <60 ml/min/1.73 m2), estimated using Modification of Diet in Renal Disease (MDRD), creatinine- and cystatin C-based (CKDEPI-CR and CKDEPI-CC) Chronic Kidney Disease Epidemiology Collaboration equations with handgrip strength (HGS). Methods: Community-dwelling males aged ≥60 years admitted to outpatient clinic were included. We used MDRD, CKDEPI-CR, and CKDEPI-CC formulas for GFR estimation and corrected these for body surface area. Muscle strength was assessed by HGS. Results: 209 men (mean age 67.8 ± 6.4) were enrolled. Sixty-two patients (29.7%) had sarcopenic HGS. Subjects with sarcopenic HGS were older, had higher rate of a GFR < 60 ml/min/1.73 m2, had lower mid-upper arm circumference; tended to have lower creatine kinase, albumin, CKDEPI-CC-GFR levels; and higher BUN/creatinine ratio and cystatin C. Multivariate logistic regression analysis revealed a CKDEPI-CC lower than 60 ml/min/1.73 m2 as the only independent factor underlying sarcopenic HGS. Higher age tended to have an independent association. Only higher age was independently associated with low HGS when other estimations were used (p = 0.013 and p = 0.021 when MDRD and CKDEPI-CR were used, respectively). Conclusions: There is a strong association of a GFR level of <60 ml/min/1.73 m2 with sarcopenic HGS, when CKDEPI-CC formula is used.

Body mass index and functional status in community dwelling older Turkish males

Abstract Disability is utmost important on an aging populations health. Obesity is associated with increased risk for disability. On-the-other-hand, higher-BMI is reported as associated with better functionality in older people in some reports defined as “obesity paradox”. There is some evidence on differential relationship between body weight status and functionality by living setting gender, and different populations. We studied the relation between body mass index and functionality in Turkish community dwelling older males accounting for the most confounding factors: age, multimorbidity, polypharmacy and nutritional status. This is a cross-sectional study in a geriatric outpatient clinic of a university hospital. Functionality was assessed with evaluation of activities of daily living (ADL) and instrumental activities of daily living (IADL) scales. Nutrition was assessed by mini-nutritional assessment test. Two hundred seventy-four subjects comprised our study cohort. Mean age was 74.4 ± 7.1 years, BMI was 25.8 ± 4.4 kg/m2. Linear regression analysis revealed significant and independent association of lower BMI with higher ADL and IADL scores (B = 0.047 and B = 0.128, respectively) (p < 0.05) and better nutritional status (B = 1.94 and B = 3.05, respectively) (p < 0.001) but not with the total number of medications. Higher IADL score was associated with younger age and lower total number of diseases (B = 0.121, B = 0.595, respectively) (p < 0.05) while ADL was not. We suggest that lower BMI is associated with better functional status in Turkish community-dwelling male older people. Our study recommends longitudinal studies with higher participants from different populations, genders and living settings are needed to comment more.

A new screening tool for self-neglect in community-dwelling older adults: IMSelf-neglect questionnaire

OBJECTIVE We aimed to develop a new screening tool for self-neglect in community-dwelling self-sufficient older adults. METHODS Istanbul Medical School Elder Self-Neglect questionnaire (IMSelf-neglect) was developed as a screening tool. Community-dwelling, self-sufficient older adults were recruited in a geriatric outpatient clinic (n = 226, 142 female, 84 male). Construct validity was based on social-workers interview as a gold-standard method. The cut-off threshold for IMSelf-neglect questionnaire was calculated from ROC-analysis using cut-off values that predicted social-workers opinion whether the older adult has self-neglect. RESULTS Mean age was 74 ± 6.5 years. The inter-rater and test-retest reliability were excellent (r = 0.887, p < .05; r = 0.942, p < .05, respectively). The internal consistency was good (Cronbachs alpha: 0.708). Cut-off threshold for IM Self-neglect questionnaire was calculated as 7 with 92.1% sensitivity and 70.7% specificity. Positive predictive value and negative predictive value of IMSelf-neglect questionnaire were 38.9% and 97.8%, respectively. There was significant moderate agreement between social workers assessment and results of IMSelf-neglect questionnaire (κ = 0.407, p < .001). The social worker confirmed 16.8% of the participants have self-neglect by the gold-standard clinical interview. Participants with self-neglect had decreased functionality, worse quality of life and tended to have more depression compared with participants without self-neglect. DISCUSSION/CONCLUSION We developed the IMSelf-neglect questionnaire as a valid and reliable tool to screen self-neglect in outpatient clinics complementary to comprehensive geriatric assessment.

Explicit versus implicit evaluation to detect inappropriate medication use in geriatric outpatients

Abstract Aim: The rates and reasons why clinicians decide not to follow recommendations from explicit-criteria have been studied scarce. We aimed to compare STOPP version 2 representing one of the most commonly used excplicit tool with the implicit comprehensive geriatric assessment mediated clinical evaluation considered as gold standard. Methods: Two hundred and six (n = 206) outpatients ≥65 years old were included. The study was designed as retrospective, cross-sectional, and randomised. STOPP version 2 criteria were systematically used to assess pre-admission treatments followed by implicit clinical evaluation regarding two questions: Were the STOPP criteria recommendations valid for the individual patient and were there any potentially inappropriate-prescription other than depicted by STOPP version 2 criteria? The underlying reason(s) and associated clinical-features were noted. Results: About 62.6% potentially inappropriate-prescriptions were identified (0.6 per-subject) according to systematic application of STOPP v2 while it was 53.4% (0.5 potentially inappropriate-prescriptions per subject) by clinician’s application of STOPP v2. Prevalence of non-compliance was 14.7% in 18 (21.7%) of 83 patients identified by systematic application. Suggestion to stop a drug was not accepted because of need of treatment despite likelihood of anticipated side-effects in about 2/3 and with no-anticipated side-effects in about 1/3 of non-compliances. Not following STOPP v2 was significantly associated with lower functional level. According to clinician’s implicit-evaluation, there were an extra 59.2% potentially inappropriate-prescriptions (0.6 per subject) in 80 (38.8%) patients yielding a total of 112.6% potentially inappropriate-prescription. Conclusions: Most of the STOPP v2 directed drug cessations are decided valid by the clinicians. In patients with higher functional dependency, it is likely that they are not followed due to palliation focussed care/patient–family preferences. There may be as much as STOPP v2 identified potentially inappropriate-prescriptions by implicit evaluation in a significant percent of geriatric patients signifying need for comprehensive geriatric evaluation in practice.

Intensive Blood Pressure Treatment in Adults Aged 60 Years or Older

TO THE EDITOR: In their valuable systematic review and meta-analysis, Weiss and colleagues (1) reviewed many studies on optimal management strategies for hypertension in older adults. They state that antihypertensive treatment effects in 2 trials (SPRINT [Systolic Blood Pressure Intervention Trial] and HYVET [Hypertension in the Very Elderly Trial]) did not differ according to frailty status. However, according to the second report on SPRINT participants (2), primary composite cardiovascular outcomes and all-cause mortality did not decrease in frail participants (P= 0.06 and 0.05, respectively) or slow gait speed (P= 0.05 and 0.28, respectively) when they received intensive compared with standard treatment (3). In HYVET, both the frailer and fitter older adults with hypertension seemed to benefit from treatment. In this trial, frailty was evaluated by the frailty index, but at most approximately 5% of participants had limitations in walking and activities of daily living. Hence, the reported lack of modification of the positive effect of antihypertensive treatment as measured by the frailty index does not supply data on older adults who specifically have slow gait speed, functional limitation, or both. Investigation of the effect of antihypertensive treatment in this population would provide a better perspective (3). In accordance with this argument, the European Society of Hypertension and the European Union Geriatric Medicine Society published a joint expert opinion article in 2016 on the management of very old, frail persons with hypertension and suggested obtaining accurate information on the functional capacity of these patients before making therapeutic decisions (4). Weiss and colleagues also state that data to assess the risks and benefits of antihypertensive treatment among institutionalized elderly patients or those with multiple comorbidities are lacking. However, the PARTAGE (Predictive Values of Blood Pressure and Arterial Stiffness in Institutionalized Very Aged Population) study assessed all-cause mortality in institutionalized persons older than 80 years according to systolic blood pressure (SBP) levels and number of antihypertensive drugs (5). The authors of this study reported a higher risk for death in patients with low SBP (<130 mm Hg) who were receiving multiple antihypertensive agents than other participants. This longitudinal study provides substantial data on the harms of using antihypertensive agents in frail older adults.

Possible side effects of metoclopramide.

In recent issue of Clinical Nutrition, we have read with a great interest the article by Ridley et al. entitled “Nutrition therapy in critically ill patientsa review of current evidence for clinicians”.[1] They show an overview of the major evidence base on nutrition therapy in critically ill patients and provide practical suggestions. They suggest metoclopramide as a prokinetic drug that can assist in the management of gastro intestinal intolerance by improving gastric emptying. But it must be carefully used because of the side effects like extrapyramidal reactions. Populations most at risk for extrapyramidal reactions include young women, children, the elderly, diabetics, patients with neurologic disorders and patients taking concurrent neuroleptic medications [2,3]. So it should be it should be emphasized in the article. Best regards.

Possible effect of decreased insulin resistance on ferritin levels after Nordic Walking training

Dear editor We read with interest the article by Kortas et al1 entitled “Effect of Nordic Walking training on iron metabolism in elderly women.” In their study, the authors investigated the effect of Nordic Walking (NW) training on serum ferritin, C-reactive protein (CRP), hepcidin, hemojuvelin, and vitamin D, which have been stated as components of the inflammatory system. In this study, while NW training significantly reduced iron stores and increased hemojuvelin and tended to reduce CRP levels, it did not affect hepcidin levels. The authors also observed a significant weight loss after training. The authors concluded NW training has pro-healthy effects manifested by decreased inflammation and a drop in iron stores. It is well known that obesity is associated with insulin resistance and physical exercise and weight loss reduce insulin resistance. Several studies indicate a positive correlation between iron levels and insulin resistance.2,3 There is also a relationship between insulin resistance and CRP levels.4 The possibility of decreased insulin resistance with weight loss after training can also contribute to the decline in CRP and ferritin levels in this study. The authors mentioned that they did not observe the anticipated increase in hepcidin levels after exercise. As the authors stated, hepcidin levels increase in response to both inflammation and exercise. Because the mean body mass index of the study population is in the overweight range, these subjects might have insulin resistance and associated inflammation. Thus, the anticipated increase in hepcidin levels with exercise might have been attenuated via decreased inflammation in this study. This two-way interaction may account for the unchanged hepcidin levels. The authors did not report insulin levels in this study and did not discuss the probable effect of insulin resistance on the relationship between ferritin and exercise. We suggest that consideration of these factors may facilitate interpretation of the findings of this study. We also suggest that insulin resistance would better be assessed in future studies in this field.

Underestimated factors may also precipitate delirium and can lead to the misinterpretation of frailty in these patients

Dear editor We have read the article entitled “Association between frailty and delirium in older adult patients discharged from hospital” by Verloo et al1 with great interest. In their study, the authors observed that frailty is strongly associated with delirium in older patients at hospital discharge. Consequently, they concluded that assessing frailty gives health care professionals the opportunity to improve the effectiveness of primary prevention strategies for delirium, by promptly ascertaining which discharged older adults are at a higher risk of presenting with that syndrome. We would like to give comments on a few points of this study. In the methodology section, the authors stated that frailty was assessed using the Edmonton Frailty Scale, which includes nine domains as two of cognitive impairment and functional dependency by using the Mini-Mental State Examination (MMSE) and Lawton Index of instrumental activities of daily life, respectively, at hospital discharge. According to these MMSE scores, patients have been divided into categories with regard to cognitive impairment. We would like to ask the authors about how they distinguished the impact of delirium on MMSE scores; because delirium itself may lead to lower MMSE scores independent of basal cognitive state. And this may cause misinterpretation of the patients as frail. Also, no information was given if the patients have had dementia diagnosis, which is known as one of the important risk factors for delirium.2 Regarding the assessment of functional dependency, the authors stated that a score of <16 indicates that the patient is independent, which is not in accordance with the original Lawton Index of instrumental activities of daily life article.3 Can the authors clarify this point? Another point is that, the authors compared only a number of daily medications between delirium and nondelirium groups both of which used a similar number of medications. However, certain medications may play a role in the risk of delirium. Anticholinergic agents, fluoroquinolones, and benzodiazepines are among those reported to precipitate delirium. We suggest that the data regarding the use of such medications may provide relevant information.4 Regarding the number of delirious patients, there is conflicting data in this study. It was stated as n=22 in the abstract, n=94 in Table 2, and n=20 in the result’s section. Thus, clarification of this confusion would be beneficial.