Marina De Rui

Polypharmacy in the Elderly

Polypharmacy is a problem of growing interest in geriatrics with the increase in drug consumption in recent years, particularly among people aged >65 years. The main reasons for polypharmacy are longer life expectancy, co-morbidity and the implementation of evidence-based clinical practice guidelines. However, polypharmacy also has important negative consequences, such as a higher risk of adverse drug reactions and a decline in medication efficacy because of reduced compliance.Comprehensive geriatric assessment (CGA) has proved effective in reducing the number of prescriptions and daily drug doses for patients by facilitating discontinuation of unnecessary or inappropriate medications. CGA has also demonstrated an ability to optimize treatment by increasing the number of drugs taken in cases where under-treatment has been identified. Greater multidimensional and multidisciplinary efforts are nonetheless needed to tackle polypharmacy-related problems in frail elderly patients.CGA should help geriatrics staff identify diseases with higher priority for treatment, thereby achieving better pharmacological treatment overall in elderly patients. The patient’s prognosis should also be considered in the treatment prioritization process.The most appropriate medication regimen should combine existing evidence-based clinical practice guidelines with data gathered from CGA, including social and economic considerations. Furthermore, for prescriptions to remain appropriate, the elderly should periodically undergo medication review, particularly as the risk or presence of multiple co-morbidities increases.This article aims to highlight the increasing impact of polypharmacy in the elderly and to underscore the role of CGA in achieving the most appropriate pharmacological treatment in this age group.

Pre-frailty and risk of cardiovascular disease in elderly men and women: the Pro.V.A. study.

BACKGROUND Frailty is an important risk factor for cardiovascular disease (CVD), but the impact of early, potentially reversible stages of frailty on CVD risk is unknown. OBJECTIVES This study sought to ascertain whether pre-frailty can predict the onset of CVD in a cohort of community-dwelling, not disabled, elderly people. METHODS A sample of 1,567 participants age 65 to 96 years without frailty or disability at baseline was followed for 4.4 years. Pre-frailty was defined as the presence of 1 or 2 modified Fried criteria (unintentional weight loss, low physical activity level, weakness, exhaustion, and slow gait speed), and incident CVD as onset of coronary artery diseases, heart failure, stroke, peripheral artery disease, or CVD-related mortality. RESULTS During follow-up, 551 participants developed CVD. Compared with participants who did not become frail, those with 1 modified Fried criterion (p = 0.03) and those with 2 criteria (p = 0.001) had a significantly higher risk of CVD, even after adjusting for several potential confounders (traditional risk factors for CVD, inflammatory markers, and hemoglobin A1c levels). Low energy expenditure (p = 0.03), exhaustion (p = 0.01), and slow gait speed (p = 0.03) were significantly associated with the onset of CVD, whereas unintentional weight loss and weakness were not. CONCLUSIONS Our findings suggest that pre-frailty, which is potentially reversible, is independently associated with a higher risk of older adults developing CVD. Among the physical domains of pre-frailty, low gait speed seems to be the best predictor of future CVD.

Effect of oral magnesium supplementation on physical performance in healthy elderly women involved in a weekly exercise program: a randomized controlled trial

BACKGROUND Magnesium deficiency is associated with poor physical performance, but no trials are available on how magnesium supplementation affects elderly peoples physical performance. OBJECTIVE The aim of our study was to investigate whether 12 wk of oral magnesium supplementation can improve physical performance in healthy elderly women. DESIGN In a parallel-group, randomized controlled trial, 139 healthy women (mean ± SD age: 71.5 ± 5.2 y) attending a mild fitness program were randomly allocated to a treatment group (300 mg Mg/d; n = 62) or a control group (no placebo or intervention; n = 77) by using a computer-generated randomization sequence, and researchers were blinded to their grouping. After assessment at baseline and again after 12 wk, the primary outcome was a change in the Short Physical Performance Battery (SPPB); secondary outcomes were changes in peak torque isometric and isokinetic strength of the lower limbs and handgrip strength. RESULTS A total of 124 participants allocated to the treatment (n = 53) or control (n = 71) group were considered in the final analysis. At baseline, the SPPB scores did not differ between the 2 groups. After 12 wk, the treated group had a significantly better total SPPB score (Δ = 0.41 ± 0.24 points; P = 0.03), chair stand times (Δ = -1.31 ± 0.33 s; P < 0.0001), and 4-m walking speeds (Δ = 0.14 ± 0.03 m/s; P = 0.006) than did the control group. These findings were more evident in participants with a magnesium dietary intake lower than the Recommended Dietary Allowance. No significant differences emerged for the secondary outcomes investigated, and no serious adverse effects were reported. CONCLUSIONS Daily magnesium oxide supplementation for 12 wk seems to improve physical performance in healthy elderly women. These findings suggest a role for magnesium supplementation in preventing or delaying the age-related decline in physical performance.

Vitamin D deficiency predicts cognitive decline in older men and women The Pro.V.A. Study

Objective: To test the hypothesis that hypovitaminosis D is associated with a higher risk of cognitive decline over a 4.4-year follow-up in a large sample of older adults. Methods: This research was part of the Progetto Veneto Anziani (Pro.V.A.), an Italian population-based cohort study of 1,927 elderly subjects. Serum 25-hydroxyvitamin D (25OHD) levels were measured at the baseline. Global cognitive function was measured with the Mini-Mental State Examination (MMSE); scores lower than 24 were indicative of cognitive dysfunction, and a decline of 3 or more points on the MMSE over the follow-up was considered as clinically significant. Analyses were adjusted for relevant confounders, including health and performance status. Results: Participants with 25OHD deficiency (<50 nmol/L) or insufficiency (50–75 nmol/L) were more likely to have declining MMSE scores during the follow-up than those who were 25OHD sufficient (≥75 nmol/L). Among participants cognitively intact (baseline MMSE scores ≥24 and without diagnosis of dementia), the multivariate adjusted relative risk (95% confidence interval [CI]) of the onset of cognitive dysfunction was 1.36 (95% CI: 1.04–1.80; p = 0.02) for those with vitamin D deficiency and 1.29 (95% CI: 1.00–1.76; p = 0.05) for those with vitamin D insufficiency by comparison with individuals with normal 25OHD levels. Conclusion: The results of our study support an independent association between low 25OHD levels and cognitive decline in elderly individuals. In cognitively intact elderly subjects, 25OHD levels below 75 nmol/L are already predictive of global cognitive dysfunction at 4.4 years.

Specific bioelectrical impedance vector reference values for assessing body composition in the Italian elderly

OBJECTIVE To obtain specific bioelectrical impedance vector reference values for the healthy elderly Italian population, and to study age- and sex-related differences in body composition. DESIGN The study group consisted of 560 healthy individuals (265 men and 295 women) aged 65 to 100 y, whose anthropometric (height, weight, and calf, arm and waist circumferences) and bioelectrical measurements (resistance [R] and reactance [Xc], at 50 kHz and 800 μA) were recorded. R (Ω) and Xc (Ω) values were standardized for stature (H, m) to obtain the classic bioelectrical values. Specific values (resistivity [Rsp] and reactivity [Xcsp], Ω·cm) were obtained by multiplying R and Xc by a correction factor (A/L) that includes an estimate of the cross-sectional area of the body (A=0.45 arm area+0.10 waist area+0.45 calf area), where L=1.1H. RESULTS Descriptive statistics were: Rsp (391.8±57.9), Xcsp (42.6±9.9), Zsp (394.2±58.2), phase angle (6.2°±1.2) in men; Rsp (462.0±80.1), Xcsp (47.9±11.2), Zsp (464.6±80.5), phase angle (5.9°±1.0) in women. The Xcsp and phase angle values showed a significant age-related decrease in both sexes, but especially in men, possibly relating to a gradual loss of muscle mass. Womens Rsp and Zsp values tended to drop, attributable to their declining proportion of fat mass. A declining sexual dimorphism was also apparent. CONCLUSIONS Specific tolerance ellipses can be used for reference purposes for the Italian population when assessing body composition in gerontological practice and for epidemiological purposes.

Assessing appendicular skeletal muscle mass with bioelectrical impedance analysis in free-living Caucasian older adults

BACKGROUND & AIMS Aging is characterized by a loss of appendicular skeletal muscle mass (ASMM) leading to physical disability and death. Bioelectrical impedance analysis (BIA) is reliable in estimating ASMM but no prediction equations are available for elderly Caucasian subjects. The aim of the study was to develop and validate an equation derived from bioelectrical impedance analysis (BIA) to predict appendicular skeletal muscle mass (ASMM) in healthy Caucasian elderly subjects, taking dual X-ray absorptiometry (DXA) as the reference method, and comparing the reliability of the new equation with another BIA-based model developed by Kyle et al. (Kyle UG, Genton L, Hans D, Pichard C, 2003). METHODS With a cross-sectional design, 296 free-living, healthy Caucasian subjects (117 men, 179 women) over 60 years of age were enrolled. Lean mass of limbs was measured with DXA to ascertain ASMM (ASMMDxA). Whole-body tetrapolar BIA was performed to measure resistance (Rz), resistance normalized for stature (RI), and reactance (Xc). The BIA multiple regression equation for predicting ASMM was developed using a double cross-validation technique. The predicted ASMM values were compared with ASMMKyle, i.e. ASMM estimates derived from the model developed by Kyle et al. (Kyle et al., 2003). RESULTS Cross-validation resulted in a unique equation using the whole sample: ASMM (kg) = -3.964 + (0.227*RI) + (0.095*weight) + (1.384*sex) + (0.064*Xc) [R(2) = 0.92 and SEE = 1.14 kg]. In our sample, ASMMKyle differed significantly from the ASMMDxA (p < 0.0001), with a mean error of -0.97 ± 1.34 kg (5.1 ± 6.9%). Unlike the present BIA prediction equation, the Kyle et al. model showed a correlation between the bias and the mean of ASMMDxA and ASMMKyle (r = -0.406, p < 0.001). CONCLUSION The new BIA equation provides a valid estimate of ASMM in older Caucasian adults.

Orthostatic Changes in Blood Pressure and Mortality in the Elderly: The Pro.V.A Study

BACKGROUND An extensive, albeit contrasting literature has suggested a possible role for orthostatic hypotension as a risk factor for cardiovascular (CVD) and non-CVD mortality, while no data are available for orthostatic hypertension. We investigated whether orthostatic changes in blood pressure (BP) were associated with any increased risk of all-cause, CVD or non-CVD mortality in a group of elderly people. METHODS Two thousand seven hundred and eighty six community-dwelling older participants were followed for 4.4 years. Participants were grouped according to whether they had a drop ≤20 mm Hg in systolic, or ≤10 mm Hg in diastolic BP (orthostatic hypotension), an increase in mean orthostatic systolic BP ≥20 (orthostatic hypertension), or normal changes within 3 minutes of orthostatism. RESULTS During follow-up, 640 subjects died, 208 of them for CVD-related reasons. Adjusted Coxs regression analysis revealed that, compared with normal changes, orthostatic hypertension was associated with higher all-cause (HR = 1.23; 95% CI: 1.02-1.39) and CVD-related mortality (HR = 1.41; 95% CI: 1.08-1.74), while orthostatic hypotension was only associated with a higher non-CVD mortality (HR = 1.19; 95% CI: 1.01-1.60). Orthostatic hypertension emerged as a predictor of all-cause mortality for: participants over 75 years old; participants with a BMI below 25 kg/m2; participants with no CVD or disabilities; and those taking less than three medications. Orthostatic hypertension also predicted CVD-related mortality in individuals with no hypertension, heart failure, coronary artery disease, or atrial fibrillation. CONCLUSIONS Orthostatic hypertension and hypotension both seem to be relevant risk factors for mortality in the elderly, orthostatic hypertension correlating with all-cause and CVD-related mortality and orthostatic hypotension with non-CVD mortality.

Association between Short Physical Performance Battery and falls in older people: the Progetto Veneto Anziani Study.

It is known that weakness in the lower limbs is associated with recurrent falls in old people. Among the tests routinely used to assess lower extremity strength, the Short Physical Performance Battery (SPPB) is one of those used most often, but its relationship with recurrent falls is poorly investigated. We aimed to determine if SPPB scores are related to recurrent falling in a sample of 2710 older-aged people, and to ascertain which test in the SPPB is most strongly associated with a higher rate of falls. In this cross-sectional study, we demonstrated that participants scoring 0-6 in the SPPB were more likely to be recurrent fallers than those scoring 10-12 (odds ratio [OR]=3.46, 95% confidence interval [CI] 2.04-5.88 in women; OR=3.82, 95% CI 1.77- 8.52, in men). SPPB scores of 7-9 were only associated with women being more likely to be recurrent fallers (OR=2.03, 95% CI 1.28-3.22). When the SPPB items were analyzed separately, even a lower score in gait speed for women was significantly associated with the presence of recurrent falls (OR=2.11; 95% CI 1.04-4.30), whereas in men only a significant increase in the time taken to complete the five timed chair stands test was associated with a higher rate of falls (OR=2.75; 95% CI 1.21-6.23). In conclusion, our study demonstrated that SPPB scores ≤6 are associated with a higher fall rate in old people of both genders; in females, even an SPPB score between 7 and 9 identifies subjects at a higher likelihood of being recurrent fallers. Among the single items of the SPPB, the most strongly associated with falls were gait speed in women and the five timed chair stands test in men.

Role of comprehensive geriatric assessment in the management of osteoporotic hip fracture in the elderly: an overview

Purpose: To highlight the advantages of comprehensive geriatric assessment (CGA) over usual care in the management of elderly patients with fragility hip fractures in terms of reducing the related mortality and disability. Method: An overview of publications on the topic was conducted using the MEDLINE and EMBASE databases. Results: Several models of geriatric and orthopedic comanagement have been developed in recent years, all characterized by a variable degree of integration, and they have been shown to reduce complications, disability and mortality in elderly hip-fracture patients. Preoperatively, CGA should identify the comorbidities that need to be treated in view of surgery, so as to reduce the related risks. After surgery, CGA should deal with medical complications and assure patients an early mobilization in order to reduce short-term mortality and contain functional decline. Before discharge, the orthogeriatric team should draw up a tailored program to promote the patient’s functional recovery and satisfactory quality of life, also covering the secondary prevention of fragility fractures by improving bone quality and reducing the risk of falls. Conclusions: Fragility hip fractures in the elderly people need to be managed by different professionals working in close cooperation and adopting a CGA. Implications for Rehabilitation Orthogeriatric management Fragility hip fracture in older people is burdened by an elevated incidence of complications, mortality and disability. The global complexity of elderly people with hip fracture requires an orthopedic and geriatric comanagement. The application of the comprehensive geriatric assessment during hospital stay is the best approach for the management of the elderly people with hip fracture. Before discharge the multidisciplinary team should design a tailored rehabilitation plan and should also consider the secondary prevention of hip fracture.

Serum 25-Hydroxyvitamin D and Incidence of Diabetes in Elderly People: The PRO.V.A. Study

CONTEXT Increasing research has shown that low levels of serum 25-hydroxyvitamin (25OHD) predict the onset of diabetes, but no research is available on this issue in elderly people. OBJECTIVE Our objective was to examine whether low serum levels of 25OHD are associated with a higher risk of incident type 2 diabetes over a lengthy follow-up in a representative group of elderly people. DESIGN AND SETTING This was a population-based cohort study as part of the Progetto Veneto Anziani (Pro.V.A.) Study over a follow-up of 4.4 years in the general community. PARTICIPANTS PARTICIPANTS included 2227 participants (1728 with follow-up visits and 499 died during the follow-up) over 65 years of age without diabetes at baseline, of 2352 initially included. MAIN OUTCOME MEASURE The main outcome measure was incident diabetes. RESULTS There were no baseline differences in known factors for the onset of diabetes (body mass index, waist circumference, total cholesterol, renal function, and hemoglobin A1c levels) between the groups with different serum 25OHD levels (≤ 25, 25-50, 50-75, and ≥ 75 nmol/L). Over a 4.4-year follow-up, 291 individuals developed diabetes, with an incidence of 28 events per 1000 person-years. No significant difference in the incidence of diabetes emerged between the baseline 25OHD groups. Coxs regression analysis, adjusted for potential confounders, revealed no relationship between low vitamin D levels and incident diabetes during the follow-up (hazard ratio [HR] = 1.05, 95% confidence interval [CI] = 0.76-1.45, P = .77; HR = 1.44, 95% CI = 0.95-1.98, P = .12; and HR = 1.37, 95% CI = 0.87-2.16, P = .17 for those with 25OHD ≤25, 25-50, and 50-75 nmol/L, respectively). CONCLUSION Baseline serum concentrations of 25OHD were not associated with the incidence of diabetes in community-dwelling elderly people over a follow-up of 4.4 years.