Jane A. Masoli

Much more medicine for the oldest old: trends in UK electronic clinical records

Background: the oldest old (85+) pose complex medical challenges. Both underdiagnosis and overdiagnosis are claimed in this group. Objective: to estimate diagnosis, prescribing and hospital admission prevalence from 2003/4 to 2011/12, to monitor trends in medicalisation. Design and setting: observational study of Clinical Practice Research Datalink (CPRD) electronic medical records from general practice populations (eligible; n = 27,109) with oversampling of the oldest old. Methods: we identified 18 common diseases and five geriatric syndromes (dizziness, incontinence, skin ulcers, falls and fractures) from Read codes. We counted medications prescribed ≥1 time in all quarters of studied years. Results: there were major increases in recorded prevalence of most conditions in the 85+ group, especially chronic kidney disease (stages 3–5: prevalence <1% rising to 36.4%). The proportions of the 85+ group with ≥3 conditions rose from 32.2 to 55.1% (27.1 to 35.1% in the 65–84 year group). Geriatric syndrome trends were less marked. In the 85+ age group the proportion receiving no chronically prescribed medications fell from 29.6 to 13.6%, while the proportion on ≥3 rose from 44.6 to 66.2%. The proportion of 85+ year olds with ≥1 hospital admissions per year rose from 27.6 to 35.4%. Conclusions: there has been a dramatic increase in the medicalisation of the oldest old, evident in increased diagnosis (likely partly due to better record keeping) but also increased prescribing and hospitalisation. Diagnostic trends especially for chronic kidney disease may raise concerns about overdiagnosis. These findings provide new urgency to questions about the appropriateness of multiple diagnostic labelling.

Obesity in Older People With and Without Conditions Associated With Weight Loss: Follow-up of 955,000 Primary Care Patients

Background: Moderate obesity in later life may improve survival, prompting calls to revise obesity control policies. However, this obesity paradox may be due to confounding from smoking, diseases causing weight-loss, plus varying follow-up periods. We aimed to estimate body mass index (BMI) associations with mortality, incident type 2 diabetes, and coronary heart disease in older people with and without the above confounders. Methods: Cohort analysis in Clinical Practice Research Datalink primary care, hospital and death certificate electronic medical records in England for ages 60 to more than 85 years. Models were adjusted for age, gender, alcohol use, smoking, calendar year, and socioeconomic status. Results: Overall, BMI 30–34.9 (obesity class 1) was associated with lower overall death rates in all age groups. However, after excluding the specific confounders and follow-up less than 4 years, BMI mortality risk curves at age 65–69 were U-shaped, with raised risks at lower BMIs, a nadir between 23 and 26.9 and steeply rising risks above. In older age groups, mortality nadirs were at modestly higher BMIs (all <30) and risk slopes at higher BMIs were less marked, becoming nonsignificant at age 85 and older. Incidence of diabetes was raised for obesity-1 at all ages and for coronary heart disease to age 84. Conclusions: Obesity is associated with shorter survival plus higher incidence of coronary heart disease and type 2 diabetes in older populations after accounting for the studied confounders, at least to age 84. These results cast doubt on calls to revise obesity control policies based on the claimed risk paradox at older ages.

Safety and Effectiveness of Statins for Prevention of Recurrent Myocardial Infarction in 12 156 Typical Older Patients: A Quasi-Experimental Study

Background: There is limited evidence on statin risk and effectiveness for patients aged 80+. We estimated risk of recurrent myocardial infarction, muscle-related and other adverse events, and statin-related incremental costs in “real-world” older patients treated with statins versus no statins. Methods: We used primary care electronic medical records from the UK Clinical Practice Research Datalink. Subhazard ratios (competing risk of death) for myocardial infarction recurrence (primary end point), falls, fractures, ischemic stroke, and dementia, and hazard ratios (Cox) for all-cause mortality were used to compare older (60+) statin users and 1:1 propensity-score-matched controls (n = 12,156). Participants were followed-up for 10 years. Results: Mean age was 76.5±9.2 years; 45.5% were women. Statins were associated with near significant reduction in myocardial infarction recurrence (subhazard ratio = 0.84, 0.69–1.02, p = .073), with protective effect in the 60–79 age group (0.73, 0.57–0.94) but a nonsignificant result in the 80+ group (1.06, 0.78–1.44; age interaction p = .094). No significant associations were found for stroke or dementia. Data suggest an increased risk of falls (1.36, 1.17–1.60) and fractures (1.33, 1.04–1.69) in the first 2 years of treatment, particularly in the 80+ group. Treatment was associated with lower all-cause mortality. Statin use was associated with health care cost savings in the 60–79 group but higher costs in the 80+ group. Conclusions: Estimates of statin effectiveness for the prevention of recurrent myocardial infarction in patients aged 60–79 years were similar to trial results, but more evidence is needed in the older group. There may be an excess of falls and fractures in very old patients, which deserves further investigation.

Outcomes of Treated Hypertension at Age 80 and Older: Cohort Analysis of 79,376 Individuals.

To estimate outcomes according to attained blood pressure (BP) in the oldest adults treated for hypertension in routine family practice.

Blood Pressure Trajectories in the 20 Years Before Death.

Importance There is mixed evidence that blood pressure (BP) stabilizes or decreases in later life. It is also unclear whether BP trajectories reflect advancing age, proximity to end of life, or selective survival of persons free from hypertension. Objective To estimate individual patient BP for each of the 20 years before death and identify potential mechanisms that may explain trajectories. Design, Study, and Participants We analyzed population-based Clinical Practice Research Datalink primary care and linked hospitalization electronic medical records from the United Kingdom, using retrospective cohort approaches with generalized linear mixed-effects modeling. Participants were all available individuals with BP measures over 20 years, yielding 46 634 participants dying aged at least 60 years, from 2010 to 2014. We also compared BP slopes from 10 to 3 years before death for 20 207 participants who died, plus 20 207 birth-year and sex-matched participants surviving longer than 9 years. Main Outcomes and Measures Clinically recorded individual patient repeated systolic BP (SBP) and diastolic BP (DBP). Results In 46 634 participants (51.7% female; mean [SD] age at death, 82.4 [9.0] years), SBPs and DBPs peaked 18 to 14 years before death and then decreased progressively. Mean changes in SBP from peak values ranged from −8.5 mm Hg (95% CI, −9.4 to −7.7) for those dying aged 60 to 69 years to −22.0 mm Hg (95% CI, −22.6 to −21.4) for those dying at 90 years or older; overall, 64.0% of individuals had SBP changes of greater than −10 mm Hg. Decreases in BP appeared linear from 10 to 3 years before death, with steeper decreases in the last 2 years of life. Decreases in SBP from 10 to 3 years before death were present in individuals not treated with antihypertensive medications, but mean yearly changes were steepest in patients with hypertension (−1.58; 95% CI, −1.56 to −1.60 mm Hg vs −0.70; 95% CI, −0.65 to −0.76 mm Hg), dementia (−1.81; 95% CI, −1.77 to −1.87 mm Hg vs −1.41; 95% CI, −1.38 to −1.43 mm Hg), heart failure (−1.66; 95% CI, −1.62 to −1.69 mm Hg vs −1.37; 95% CI, −1.34 to −1.39 mm Hg), and late-life weight loss. Conclusions and Relevance Mean SBP and DBP decreased for more than a decade before death in patients dying at 60 years and older. These BP decreases are not simply attributable to age, treatment of hypertension, or better survival without hypertension. Late-life BP decreases may have implications for risk estimation, treatment monitoring, and trial design.

Proton-Pump Inhibitors and Long-Term Risk of Community-Acquired Pneumonia in Older Adults: PPIs and pneumonia

To estimate associations between long‐term use of proton pump inhibitors (PPIs) and pneumonia incidence in older adults in primary care.

Proton-Pump Inhibitors and Fragility Fractures in Vulnerable Older Patients

This research is funded by the National Institute for Health Research (NIHR), grant number: PB-PG-0214-3309. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the UK Department of Health.

Clinical Outcomes of CADASIL-Associated NOTCH3 Mutations in 451,424 European Ancestry Community Volunteers

This report is independent research supported by the National Institute for Health Research (NIHR Doctoral Research Fellowship, Dr. Jane Masoli, DRF-2014-07-177).

Impact of Low Cardiovascular Risk Profiles on Geriatric Outcomes: Evidence From 421,000 Participants in Two Cohorts

Abstract Background Individuals with low cardiovascular risk factor profiles experience lower rates of cardiovascular diseases, but associations with geriatric syndromes are unclear. We tested whether individuals with low cardiovascular disease risk, aged 60–69 years old at baseline in two large cohorts, were less likely to develop aging-related adverse health outcomes. Methods Data were from population representative medical records (Clinical Practice Research Datalink [CPRD] England, n = 239,591) and healthy volunteers (UK Biobank [UKB], n = 181,820), followed for ≤10 years. A cardiovascular disease risk score (CRS) summarized smoking status, LDL-cholesterol, blood pressure, body mass index, fasting glucose and physical activity, grouping individuals as low (ie, all factors near ideal), moderate, or high CRS. Logistic regression, Cox models, and Fine and Grey risk models tested the associations between the CRS and health outcomes. Results Low CRS individuals had less chronic pain (UKB: baseline odds ratio = 0.52, confidence interval [CI] = 0.50–0.54), lower incidence of incontinence (CPRD: subhazard ratio [sub-HR] = 0.75, 0.63–0.91), falls (sub-HR = 0.82, CI = 0.73–0.91), fragility fractures (sub-HR = 0.78, CI = 0.65–0.93), and dementia (vs. high risks; UKB: sub-HR = 0.67, CI = 0.50–0.89; CPRD: sub-HR = 0.79, CI = 0.56–1.12). Only 5.4% in CPRD with low CRS became frail (Rockwood index) versus 24.2% with high CRS. All-cause mortality was markedly lower in the low CRS group (vs. high CRS; HR = 0.40, 95% CI = 0.35–0.47). All associations showed dose–response relationships, and results were similar in both cohorts. Conclusions Persons aged 60–69 years with near-ideal cardiovascular risk factor profiles have substantially lower incidence of geriatric conditions and frailty. Optimizing cardiovascular disease risk factors may substantially reduce the burden of morbidity in later life.

Reply to Comments on: Proton Pump Inhibitors and Long-term Risk of Community-acquired Pneumonia in Older Adults: PPIs and pneumonia

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