Rissane Ourabah

Primary care management of non-institutionalized elderly diabetic patients: The S.AGES cohort – Baseline data

AIM S.AGES is a multicenter prospective cohort study of non-institutionalized patients aged 65 and over with atrial fibrillation, type 2 diabetes or chronic pain. Its objective is to describe the medical management in primary care. This article presents the baseline characteristics of subjects in the diabetes subcohort and compares the results to those from cohorts of older diabetic patients. METHODS From April 2009 to June 2011, 983 patients were included in the diabetes subcohort by 213 primary care providers. Demographic data, geriatric parameters and the history, characteristics and treatment of the diabetes were recorded at baseline. RESULTS The mean age was 76.7 ± 5.9 years. Most patients were living independently, with no cognitive impairment and in relatively good health. The duration of diabetes was 11.3 ± 8.7 years with average HbA1c of 6.9 ± 1.0%. 20% of patients had macrovascular disease, 33% renal failure, 14.6% ocular complication and 7.1% neuropathy. The first-line antidiabetic treatment was metformin (61.2%) and 18% of patients had used insulin. Treatment intensified with the worsening of diabetic symptoms. When compared to those from French and North American cohorts, the results showed increased complications and use of insulin with age, disease duration and severity. CONCLUSION Due to the method of recruitment, S.AGES patients were generally healthy with well-controlled diabetes. However, the results were consistent with those from other cohorts. Three-year follow-up is expected to study the management of diabetic patients aged 65 and over in primary care.

Therapeutic management in ambulatory elderly patients with atrial fibrillation: The S.AGES cohort

Few epidemiologic studies have specifically focused on very old community dwelling population with atrial fibrillation (AF). The objectives of the AF-S.AGES cohort were to describe real-life therapeutic management of non-institutionalized elderly patients with AF according to age groups, i.e., 65–79 and ≥ 80 and to determine the main factors associated with anticoagulant treatment in both groups.MethodsObservational study (N=1072) aged ≥ 65 years old, recruited by general practitioners. Characteristics of the sample were first evaluated in the overall sample and according to age (< 80 or ≥ 80 years) and to use of anticoagulant treatment at inclusion. Logistic models were used to analyze the determinants of anticoagulant prescription among age groups.ResultsMean age was 78.0 (SD=6.5) years and 42% were ≥ 80 years. Nineteen percent had paroxysmal AF, 15% persistent, 56% permanent and 10% unknown type, 77% were treated with vitamin K antagonists (VKA), 17% with antiplatelet therapy with no differences between age groups. Rate-control drugs were more frequently used than rhythm-control drugs (55% vs. 37%, p < 0.001). VKA use was associated with permanent AF, younger age and cancer in patients ≥ 80 years old and with permanent AF and preserved functional autonomy in patients < 80 years old. Hemorrhagic scores were independently associated with non-use of VKA whereas thromboembolic scores were not associated with VKA use.ConclusionsIn this elderly AF outpatient population, use of anticoagulant therapy was higher even after 80 years than in previous studies suggesting that recent international guidelines are better implemented in the elderly population.

What role does the general practitioner in France play among cancer patients during the initial treatment phase with intravenous chemotherapy? A qualitative study

Abstract Background: France’s ethical and legal principles place general practitioners (GPs) at the forefront of cancer patient management, coordination, and follow-up. The objective of this study was to determine the actual role of GPs in the follow-up phase as well as patient perspectives on their GPs. Method: A multidisciplinary group of researchers conducted this qualitative study based on in-depth interviews of 50 patients managed at two cancer centres. A content analysis method was used to analyse the study data. Results: According to the patients interviewed for this study, their GPs were relatively ineffective at managing medical problems related to cancer by comparison with their oncologists. Nonetheless, the patients had all consulted their GPs during the interval between the diagnosis and our interview. Reasons given for consulting their GPs included administrative matters, psychological support, reassurance, and advice, but also to a lesser extent, medical management. Conclusion: Patients’ perspectives called attention to two aspects of the role of GPs in the French healthcare system: (a) the importance of GPs within an effective system for managing cancer patients, and (b) for some patients, GPs’ relative lack of medical skill compared to oncologists.

Association between Cardiovascular Drugs and Chronic Kidney Disease in Non‐Institutionalized Elderly Patients

Concern about the renal safety of commonly used cardiovascular drugs with demonstrated clinical benefit appears to be an obstacle to their use in the elderly. The objective was to describe the relationship between cardiovascular drugs and chronic kidney disease (CKD) in elderly individuals in the real‐life setting. This is an ancillary study of the prospective non‐interventional S.AGE (aged individuals) cohort. General physicians were free to prescribe any drug their patients needed. The participants were non‐institutionalized patients aged 65 years and older treated by their primary physician for either chronic pain or atrial fibrillation or type 2 diabetes mellitus. The estimated glomerular filtration rate (eGFR) derived from the CKD‐EPI formula was determined at inclusion and every year during 2 years of follow‐up. This study comprised 2505 patients aged 77.8 ± 6.2 years. At inclusion, the factors associated with CKD (eGFR < 60 ml/min/1.73 m2) in multivariate analysis were age, female gender, hypertension, heart failure, history of atherothrombotic disease and renin angiotensin system blockers, loop diuretics and calcium channel inhibitors. Introduction of each of these three drug classes during the follow‐up period led to only a small decrease in the eGFR: −3.8 ± 12.7 (p < 0.0006), −2.2 ± 12.0 (p < 0.003) and −1.0 ± 13.4 ml/min./1.73 m2 (NS), respectively. Only the introduction of loop diuretics was associated with CKD (OR 1.91, 95% CI: 1.25–2.90; p = 0.002). Renal safety of cardiovascular drugs in the elderly appears acceptable and should not be a barrier to their use.

Cardiovascular Drugs and Metformin Drug Dosage According to Renal Function in Non‐Institutionalized Elderly Patients

Adaptation of drug dosage to kidney function is a common problem in general practice. The aim was to describe adaptation of cardiovascular drugs and metformin according to renal function and its association with mortality with regard to metformin in a cohort of elderly patients. This was an ancillary study to the S.AGES cohort made up of patients over 65 years of age managed by their general practitioner under real‐life conditions and followed up prospectively for 3 years. The medications studied were digoxin, spironolactone and metformin. Adaptation of their daily dose according to renal function (eGFR according to CKD/EPI) was compared to that recommended in the summaries of product characteristics (SPCs) or international scientific societies (ISS). A total of 900 patients were included, including 588 on metformin. At baseline, dose adjustment according to renal function was 100% and 87.6% (95% CI: 82.6–92.6) for patients on digoxin and spironolactone respectively. For metformin, only 71.3% (95% CI: 67.6–74.9) or 78.1% (95% CI: 74.7–81.4) of patients had their dosage adapted at inclusion according to their renal function depending on whether the SPCs or ISS recommendations were considered. During the 3‐year follow‐up period, 42/588 patients died (none from lactic acidosis). At inclusion, a metformin dosage not adapted for renal function according to ISS was not associated with an increase in all‐cause mortality (OR 1.7; 95% CI 0.6–5.0, p = 0.32). In conclusion, approximately one‐quarter of elderly patients treated with metformin do not have their dosage adapted for renal function according to ISS although there is no increase in mortality after follow‐up for 3 years.

Relationship between achieved personalized glycaemic targets and monitoring of clinical events in elderly diabetic patients

AIM Recent guidelines for the management of type 2 diabetes (T2DM) in the elderly recommend adjusting the therapeutic target (HbA1c) according to the patients health. Our study aimed to explore the association between achieving the recommended personalized HbA1c target and the occurrence of major clinical events under real-life conditions. METHODS The T2DM S.AGES cohort was a prospective multicentre study into which 213 general practitioners recruited 983 non-institutionalized T2DM patients aged>65 years. The recommended personalized HbA1c targets were<7%, <8% and <9% for healthy, ill and very ill patients, respectively. Major clinical events (death from any cause, major vascular events and/or hospitalization) were recorded during the 3-year follow-up. Mixed-effects logistic regression models were used for the analyses. RESULTS Of the 747 patients analyzed at baseline, 551 (76.8%) were at their recommended personalized HbA1c target. During follow-up, 391 patients (52.3%) experienced a major clinical event. Of the patients who did not achieve their personalized HbA1c target (compared with those who did), the risk (OR) of a major clinical event was 0.95 (95% CI: 0.69-1.31; P=0.76). The risk of death, major vascular event and hospitalization were 0.88 (95% CI: 0.40-1.94; P=0.75), 1.14 (95% CI: 0.7-1.83; P=0.59) and 0.84 (95% CI: 0.60-1.18; P=0.32), respectively. CONCLUSION Over a 3-year follow-up period, our results showed no difference in risk of a major clinical event among patients, regardless of whether or not they achieved their personalized recommended HbA1c target. These results need to be confirmed before implementing a more permissive strategy for treating T2DM in elderly patients.

Gender-Related Differences in the Control of Cardiovascular Risk Factors in Primary Care for Elderly Patients With Type 2 Diabetes: A Cohort Study

OBJECTIVE The aim of this study was to estimate the association between gender and control of diabetes and other cardiovascular risk factors in elderly patients with type 2 diabetes mellitus. METHODS The sujets âgés cohort is an observational study whose main objective was to describe the real-life management of elderly patients with type 2 diabetes mellitus in France. Nine hundred eighty-three patients with diabetes (517 men and 466 women) were recruited by 213 general practitioners and were followed up prospectively every 6 months for 3 years. Diabetes, hypertension and dyslipidemia were considered controlled if the glycated hemoglobin (A1C) was ≤7%, blood pressure was <140/90 mm Hg and low-density lipoprotein (LDL) cholesterol was ≤100 mg/dL. A1C levels and blood pressure measurements were recorded every 6 months for all patients. LDL cholesterol levels were optionally sampled every year. RESULTS Women were older than men (77.3±5.72 vs. 76.1±6.01 years), more likely to be alone, less likely to be smokers/ex-smokers and less likely to have cardiovascular disease at baseline. Mean A1C levels of female patients (6.98%±1.03%) did not differ from those of male patients (6.91%±0.96%). Mean blood pressure measurements during follow up were not different between male and female patients. In contrast, female patients had significantly higher LDL cholesterol levels than male counterparts (105.2±32.6 vs. 94.9±29.1 mg/dL), regardless of statin therapy. CONCLUSION Our results suggest no difference in the management of cardiovascular risk factors between elderly female patients with type 2 diabetes mellitus and their male counterparts, except for LDL cholesterol, which is significantly higher in women.

0456: Therapeutic management in ambulatory elderly patients with atrial fibrillation: the S.AGES cohort

Few data on therapeutic management of patients over 80 years with nonvalvular atrial fibrillation (AF) are available in general population. Objectives The objectives of the AF-S.AGES cohort (Sujets AGES) were to describe real-life therapeutic management of non-institutionalized elderly subjects with AF according to age groups, i.e., 65-79 and ≥80 years and to determine factors associated with anticoagulant treatment. Methods General practitioners recruited 1072 patients aged >65 years old between 2009 and 2011. General characteristics were first evaluated in the overall sample and according to age groups and use of anticoagulant treatment at inclusion. Results Mean age was 78.0 (SD 6.5) years and 42% were older than 80 years. In the overall sample, 19% of patients had paroxysmal AF, 15% persistent, 56% permanent and for 10% AF type was unknown. Vitamin K antagonists (VKA) were used in 77% of patients, antiplatelet therapy in 17% and 12% of patients did not receive any antithrombotic treatment. There were no differences between age-groups ( Conclusions We observed a higher use of anticoagulant therapy in elderly AF outpatients even after 80 years when compared with previous studies. These results suggest that recent international guidelines are better implemented in the elderly population.