Acetazolamide Tolerance in Acute Decompensated Heart Failure: An Observational Study.

Objectives: This real-life study aimed to evaluate the safety of acetazolamide (ACZ), a carbonic anhydrase inhibitor with diuretic effects. ACZ has recently been proven to improve decongestion in the context of patients hospitalized for acute heart failure (HF). However, data in terms of safety are lacking. Methods: We conducted a monocentric observational prospective study from November 2023 to February 2024 in a 12-bed cardiology department, recording adverse events (hypotension, severe metabolic acidosis, severe hypokalemia and renal events) during in-hospital HF treatment. All patients hospitalized for acute HF during the study period treated with ACZ (500 mg IV daily for 3 days) on top of IV furosemide (n = 28, 48.3%) were compared with patients who have been treated with IV furosemide alone (n = 30, 51.7%). Results: The patients treated with ACZ were younger than those without (median age 78 (range 67-86) vs. 85 (79-90) years, respectively, p = 0.01) and had less frequent chronic kidney disease (median estimated glomerular fraction rate (60 (35-65) vs. 38 (26-63) mL/min, p = 0.02). As concerned adverse events during HF treatment, there were no differences in the occurrences of hypotension (three patients [10.7%] in the ACZ group vs. four [13.3%], p = 0.8), renal events (four patients [14.3%] in the ACZ group vs. five [16.7%], p = 1) and severe hypokalemia (two [7.1%] in the ACZ group vs. three [10%], p = 1). No severe metabolic acidosis occurred in either group. Conclusions: Although the clinical characteristics differed at baseline, with younger age and better renal function in patients receiving ACZ, the tolerance profile did not significantly differ from patients receiving furosemide alone. Additional observational data are needed to further assess the safety of ACZ-furosemide combination in the in-hospital management of HF, especially in older, frail populations.

Long-Term Survival After Aspiration Pneumonia in Older Inpatients: A Comparative Study.

OBJECTIVES: Aspiration pneumonia (AsP), a leading cause of death in older people, remains poorly studied. We aimed to evaluate short- and long-term prognosis after AsP in older inpatients. DESIGN: Retrospective cohort study. SETTING AND PARTICIPANTS: All consecutive patients aged ≥75 years hospitalized in a 62-bed acute geriatric unit during a 1-year period. METHODS: We compared clinical characteristics and overall 2-year survival between patients with a main diagnosis of AsP, patients with other types of acute pneumonia (non-AsP), and patients hospitalized for another cause. RESULTS: Among the 1774 patients hospitalized over 1 year (median age: 87 years, 41% female), 125 (7%) had a primary diagnosis of acute pneumonia, of whom 39 (31%) had AsP and 86 (69%) non-AsP. Patients with AsP were more frequently male, lived more frequently in a nursing home, and had a more frequent history of stroke or neurocognitive disorders. Mortality rates were much higher after AsP, reaching 31% at 30 days (vs 15% after Non-AsP and 11% in the rest of the cohort, P < .001), and 69% 2 years after admission (vs 56% and 49%, P < .001). After adjustment for confounders, AsP was significantly associated with mortality but non-AsP was not [adjusted hazard ratio (95% CI): 3.09 (1.72-5.57) at 30 days and 1.67 (1.13-2.45) at 2 years for AsP; 1.36 (0.77-2.39) and 1.14 (0.85-1.52) for non-AsP]. However, among patients who survived at 30 days, mortality did not significantly differ between the 3 groups (P = .1). CONCLUSIONS AND IMPLICATIONS: In an unselected cohort of patients hospitalized in an acute geriatric unit, a third of AsP patients died within the first month after admission. However, among those surviving at 30 days, long-term mortality did not significantly differ from the rest of the cohort. These findings underline the importance of optimizing the early management of AsP.

Apyrexia improves the prognostic value of quick SOFA in older patients with acute pneumonia or bacteremic urinary tract infection.

PURPOSE: Apyrexia is increasingly recognized as an indicator of inadequate inflammatory response in older patients with suspected infection. We aimed to evaluate whether temperature at admission could improve the prognostic value of the Quick Sequential Organ Failure Assessment (qSOFA) for predicting in-hospital mortality after acute infection. METHODS: We created a new score, named qSOFAGE (qSOFA in GEriatrics), by adding apyrexia as an item to the existing qSOFA (+ 1 point if temperature at admission ≤ 38 °C). We compared the prognostic value of the qSOFA, the qSOFAGE and temperature at admission for predicting in-hospital mortality after acute infection in two cohorts including older patients with acute pneumonia (AP) or bacteremic urinary tract infection (UTI). RESULTS: 217 consecutive patients aged ≥ 75 hospitalized for AP (first cohort) and 105 for bacteremic UTI (second cohort) were recorded. Temperature at admission was strongly inversely correlated with in-hospital mortality in both cohorts (Odds Ratios per °C (95% Confidence Interval): 0.60 (0.45-0.80) and 0.46 (0.27-0.79) for AP and UTI. respectively). Adding the temperature ≤ 38 °C item to the qSOFA markedly improved its predictive value for in-hospital mortality in the two groups: C-statistics for qSOFAGE vs. qSOFA: 0.63 (0.53-0.73) vs. 0.56 (0.46-0.67) in AP cohort; 0.74 (0.58-0.89) vs. 0.69 (0.53-0.85) in UTI cohort. For patients with qSOFAGE ≥ 3, in-hospital mortality reached 37% after AP and 55% after bacteremic UTI. CONCLUSION: Temperature at admission was strongly correlated with mortality in these two cohorts of older patients hospitalized for acute infection. The next step will be to validate this score in cohorts of older patients with suspected infection.

Transfusion in Older Anemic Patients: Should the Troponin Value Be Taken into Account?

BACKGROUND: Anemia is common in older individuals, but it is not known whether the prognostic impact of transfusion differs according to cardiac troponin concentration. METHODS: During this 2-year retrospective study in an acute geriatric unit, 514 patients with hemoglobin <10 g/dL and troponin sampling were included. Thirty-day and 1-year mortality were compared according to transfusion status and troponin and hemoglobin levels. RESULTS: Of the 514 anemic patients included (median age 88 years), 157 (31%) had elevated troponin concentrations. These patients were more likely to die at 30 days (49% vs 27%, P < .001) and 1 year (65% vs 51%, P = .004) than patients with normal values. Among patients with elevated troponin concentrations, 30-day mortality tended to be lower in transfused than in not-transfused patients (hazard ratio 0.48; 95% confidence interval, 0.21-1.08; P = .07). This association was not found in patients without troponin elevation (hazard ratio 1.09; 95% CI, 0.61-1.93; P = .8). Transfusion was associated with 30-day survival in patients with hemoglobin ≤8 g/dL. It was also associated with excess 1-year mortality in patients with hemoglobin >8 g/dL. CONCLUSIONS: This pilot study suggests that transfusion could be associated with better 30-day outcomes in older anemic patients with anemia-related myocardial injury. Thus, troponin levels could be involved in decision-making relative to transfusion in anemic older patients. Clinical trials are needed to establish the benefit of transfusion in patients with elevated troponins.

New horizons in Type 2 myocardial infarction: pathogenesis, assessment and management of an emerging geriatric disease.

Type 2 myocardial infarction (MI) is characterised by a functional imbalance between myocardial oxygen supply and demand in the absence of a thrombotic process, leading to myocardial necrosis. This type of MI was relatively unknown among clinicians until the third universal definition of MI was published in 2017, differentiating Type 2 from Type 1 MI, which follows an acute atherothrombotic event. The pathogenesis, diagnostic and therapeutic aspects of Type 2 MI are described in the present review. Type 2 MI is a condition that is strongly linked to age because of vascular ageing concerning both epicardic vessels and microcirculation, age-related atherosclerosis and stress maladaptation. This condition predominantly affects multimorbid individuals with a history of cardiovascular disease. However, the conditions that lead to the functional imbalance between oxygen supply and demand are frequently extra-cardiac (e.g. pneumonia or anaemia). The great heterogeneity of the underlying etiological factors requires a comprehensive approach that is tailored to each case. In the absence of evidence for the benefit of invasive reperfusion strategies, the treatment of Type 2 MI remains to date essentially based on the restoration of the balance between oxygen supply and demand. For older co-morbid patients with Type 2 MI, geriatricians and cardiologists need to work together to optimise etiological investigations, treatment and prevention of predisposing conditions and precipitating factors.

Criteria for taking an advance decision to limit the transfer to intensive care of patients aged 75 and over, hospitalised in an acute geriatric unit.

OBJECTIVE: Due to the diversity of the elderly population and medical practices, the decision to transfer elderly patients to an intensive care unit is complex. This study aimed to identify the criteria used to take an advance decision to limit transfer to an intensive care unit of patients hospitalised in an acute geriatric unit. METHODS: This retrospective study included, over a ten-month period, patients >75 years and hospitalised in an acute geriatric unit. They were divided into two groups according to whether or not an advanced decision to limit transfer to an intensive care unit had been taken. RESULTS: In total, 906 elderly patients were included in the study. Of them, 446 had no advance decision to limit transfer to an ICU. Univariate analysis showed a correlation between an advance decision to limit transfer to an ICU and a Mini Mental State Examination (MMSE) score of less than 20/30. Malnutrition had no impact on the advance decision. In multivariate analysis, the factors associated with an advance decision to limit transfer to an ICU were an age > 85 years, a hospitalisation in the last six months (Odds Ratio (OR) = 1.72, Confidence Interval (CI) 95% [1.23-2.39]), residence in a nursing home (OR = 1.93, 95% CI [1.18-0.16]) and the presence of bedsores (OR = 2.44, 95% CI [1.20-0.98]). A zero Charlson score was associated with the absence of an advance decision to limit transfer to an ICU (OR = 0.42, 95% CI [0.26-0.67]). CONCLUSION: Some criteria are common to geriatricians, intensive care doctors and emergency physicians, while others are discordant, illustrating differences in physicians' practices.

Prognostic impact of systolic blood pressure in acute heart failure with preserved ejection fraction in older patients.

AIMS: Recent guidelines recommend a systolic blood pressure (SBP) target below 130 mmHg in heart failure patients with preserved ejection fraction (HFpEF), whatever their age. We investigated whether this intensive SBP control was associated with better survival in very old adults hospitalized for acute HFpEF. METHODS AND RESULTS: We conducted an observational study in an acute geriatric unit: all consecutive patients discharged from hospital for acute heart failure from 1 March 2019 to 29 February 2020 with a diagnosis of HFpEF were included. Re-hospitalization and all-cause mortality at 1 year were compared according to the mean SBP at discharge (patients with a mean SBP < 130 mmHg vs. those with SBP ≥ 130 mmHg). We included 81 patients with a mean age of 89 years. Among them, 47 (58%) were re-hospitalized and 37 (46%) died at 1 year. All-cause mortality (hazard ratio [HR] [95% confidence interval]: 1.50 [0.75-2.98], P = 0.2) and re-hospitalization rate (HR: 1.04 [0.58-1.86], P = 0.90) at 1 year did not significantly differ between patients with SBP ≥ 130 mmHg and those with SBP < 130 mmHg at discharge. However, a prescription for antihypertensive drugs at discharge was associated with a better long-term prognosis (all-cause mortality: HR: 0.42 [0.20-0.88], P = 0.02; re-hospitalization rate: HR: 0.56 [0.28-1.10], P = 0.09). CONCLUSIONS: Although SBP < 130 mmHg at discharge was not associated with a better prognosis among very old patients hospitalized for acute HFpEF, the prescription of antihypertensive drugs was associated with mortality and re-hospitalization rates that were reduced by half. Future prospective studies are needed to assess target blood pressure in very elderly patients with HFpEF.

[Criteria of early limitation of transfer in intensive care unit of patients aged 75 and over hospitalized in an acute geriatric unit]. / Critères de limitation anticipée du transfert en réanimation des patients âgés de 75 ans et plus hospitalisés dans un service de gériatrie aiguë.

Because of heterogeneity of the elderly population and medical practices, the decision of admission of elderly patients (EP) in intensive care unit is more complex. This study aimed to determine the decision criteria for an early limitation of transfer in intensive care unit (ELTICU) of patients hospitalized in an acute geriatric unit. This retrospective study included, over a 10-month period, patients ≥75 years and hospitalized in an acute geriatric unit. They were divided into 2 groups according to whether or not an ELTICU decision was taken. In total, 906 EP were included among them 446 with no ELTICU decision. Univariate analysis showed a correlation between ELTICU and a Mini Mental Status score of less than 20/30. Malnutrition had no impact on ELTICU decision. In multivariate analysis, the factors associated with an ELTICU decision were an age ≥ 85 years, an hospitalization in the last 6 months (Odds Ratio (OR) = 1.72, Confidence Interval (CI) 95% [1.23-2.39]), life in a nursing home (OR = 1.93, 95% CI [1.18-3.16]) and the presence of bedsore(s) (OR = 2.44, 95% CI [1.20-4.98]). A null Charlson score was associated with the absence of an ELTICU decision (OR = 0.42, 95% CI [0.26-0.67]). Some criteria are shared between geriatricians, resuscitators and emergency physicians, while others are discordant, illustrating differences in physicians' practices.

Level of Medical Intervention in Geriatric Settings: Decision Factors and Correlation With Mortality.

OBJECTIVES: Level of medical intervention (LMI) has to be adapted to each patient in geriatric care. LMI scales intend to help nonintensive care (NIC) decisions, giving priority to patient choice and collegial discussion. In the present study, we aimed to assess the parameters associated with the NIC decision and whether these parameters differ from those associated with in-hospital mortality. DESIGN: Prospective observational study. SETTING AND PARTICIPANTS: All consecutive patients from a French 62-bed acute geriatric unit over 1 year. METHODS: Factors from the geriatric assessment associated with the decision of NIC were compared with those associated with in-hospital and 1-year mortality, in univariate and multivariate analyses. RESULTS: In total, 1654 consecutive patients (median age 87 years) were included. Collegial reflection led to NIC decision for 532 patients (32%). In-hospital and 1-year mortality were 22% and 54% in the NIC group vs 2% and 27% in the rest of the cohort (P < .001 for both). In multivariable analysis, high Charlson Comorbidity Index [odds ratio (OR) 1.15, 95% confidence interval (CI) 1.06-1.23, per point], severe neurocognitive disorders (OR 2.78, 95% CI 1.67-4.55), dependence (OR 1.92, 95% CI 1.45-2.59), and nursing home residence (OR 2.38, 95% CI 1.85-3.13) were highly associated with NIC decision but not with in-hospital mortality. Conversely, acute diseases had little impact on LMI despite their high short-term prognostic burden. CONCLUSIONS AND IMPLICATIONS: Neurocognitive disorders and dependence were strongly associated with NIC decision, even though they were not significantly associated with in-hospital mortality. The decision-making process of LMI therefore seems to go beyond the notion of short-term survival.

Atypical Presentation of Bacteremic Urinary Tract Infection in Older Patients: Frequency and Prognostic Impact.

In older patients, urinary tract infection (UTI) often has an atypical clinical presentation, making its diagnosis difficult. We aimed to describe the clinical presentation in older inpatients with UTI-related bacteremia and to determine the prognostic impact of atypical presentation. This cohort study included all consecutive patients older than 75 years hospitalized in a university hospital in 2019 with a UTI-related gram-negative bacillus (GNB) bacteremia, defined by blood and urine cultures positive for the same GNB, and followed up for 90 days. Patients with typical symptoms of UTI were compared to patients with atypical forms. Among 3865 inpatients over 75 with GNB-positive urine culture over the inclusion period, 105 patients (2.7%) with bacteremic UTI were included (mean age 85.3 ± 5.9, 61.9% female). Among them, UTI symptoms were reported in only 38 patients (36.2%) and 44 patients (41.9%) had no fever on initial management. Initial diagnosis of UTI was made in only 58% of patient. Mortality at 90 days was 23.6%. After adjustment for confounders, hyperthermia (HR = 0.37; IC95 (0.14-0.97)) and early UTI diagnosis (HR = 0.35; IC95 (0.13-0.94)) were associated with lower mortality, while UTI symptoms were not associated with prognosis. In conclusion, only one third of older patients with UTI developing bacteremia had UTI symptoms. However, early UTI diagnosis was associated with better survival.

Troponin Elevation in Older Patients with Acute Pneumonia: Frequency and Prognostic Value.

Cardiovascular (CV) events are particularly frequent after acute pneumonia (AP) in the elderly. We aimed to assess whether cardiac troponin I, a specific biomarker of myocardial injury, independently predicts CV events and death after AP in older inpatients. Among 214 consecutive patients with AP aged ≥75 years admitted to a university hospital, 171 with a cardiac troponin I sample in the 72 h following diagnosis of AP were included, and 71 (42%) were found to have myocardial injury (troponin > 100 ng/L). Patients with and without myocardial injury were similar in terms of age, gender and comorbidities, but those with myocardial injury had more severe clinical presentation (median (interquartile range) Pneumonia Severity Index: 60 (40-95) vs. 45 (30-70), p = 0.003). Myocardial injury was strongly associated with in-hospital myocardial infarction (25% vs. 0%, p < 0.001), CV mortality (11 vs. 1%, p = 0.003) and all-cause mortality (34 vs. 13%, p = 0.002). After adjustment for confounders, myocardial injury remained a strong predictive factor of in-hospital mortality (odds ratio (95% confidence interval): 3.32 (1.42-7.73), p = 0.005) but not one-year mortality (1.61 (0.77-3.35), p = 0.2). Cardiac troponin I elevation, a specific biomarker of myocardial injury, was found in nearly half of an unselected cohort of older inpatients with AP and was associated with a threefold risk of in-hospital death.

Iron in the General Population and Specificities in Older Adults: Metabolism, Causes and Consequences of Decrease or Overload, and Biological Assessment.

Iron is involved in many types of metabolism, including oxygen transport in hemoglobin. Iron deficiency (ID), ie a decrease in circulating iron, can have severe consequences. We provide an update on iron metabolism and ID, highlighting the particularities in older adults (OAs). There are three iron compartments in the human body: 1) the functional compartment, which consists of heme proteins including hemoglobin, myoglobin and respiratory enzymes; 2) iron reserves (IR), which consist mainly of liver stocks and are stored as ferritin; and 3) transferrin. There are two types of ID. Absolute ID is characterized by a decrease in IR. Its main pathophysiological mechanism is bleeding, which is often digestive and can be due to neoplasia, frequent in OAs. Biological assessment shows low serum ferritin and transferrin saturation (TS) levels. Furthermore, hypochromic microcytic anemia is frequent, and the serum-soluble transferrin receptor (sTfR) level is high. Functional ID, in which IR are high or normal, is due to inflammation, which is also frequent in OAs, particularly in its chronic form. Biological assessments show high serum ferritin, normal or low TS, and normal sTfR levels. Moreover, C-reactive protein is elevated, and there is moderate non-regenerative non-macrocytic anemia. The main characteristics of iron metabolism anomalies in the elderly are the high frequency of ID (20% of ID with anemia in adults ≥85 years) and the severity of its consequences, which include cognitive impairment in case of ID or iron overload and decrease of physical activity in case of ID. In conclusion, causes of ID are frequently intertwined in OAs as a result of the polymorbidity that characterizes them. ID can have dramatic consequences, especially in frail OAs. Thus, measuring the appropriate biological markers prevents errors in the positive diagnosis of ID type, clarifies etiology, and informs treatment-related decision-making.

Bedside chest ultrasound to distinguish heart failure from pneumonia-related dyspnoea in older COVID-19 patients.

AIMS: In the older population, acute heart failure is a frequent, life-threatening complication of COVID-19 that requires urgent specific care. We aimed to explore the impact of point-of-care chest ultrasound (CUS) use in older bedridden inpatients during the COVID-19 pandemic as a tool to distinguish between cardiogenic pulmonary oedema and isolated viral pneumonia-related dyspnoea. METHODS AND RESULTS: This prospective series included 16 patients aged 75 or older, hospitalized for acute dyspnoea in an acute geriatric unit of a university hospital and testing positive for a SARS-Cov2 infection. We collected demographic characteristics, medical history, biological screening, clinical symptoms, CUS findings (n = 16) and chest CT-scan conclusions (n = 14). Mean age was 89 years (77-97). All patients presented asthenia and dyspnoea, 56% complained of coughing and diarrhoea, and 50% had fever. Acute heart failure was clinically suspected in seven patients. At CUS, evidence of heart failure was confirmed in three patients (including one without clinical suspicion); interstitial syndrome was confirmed in 12 patients on CUS vs. 9 patients with CT. CONCLUSIONS: In older patients with COVID-19 and acute dyspnoea, the use of point-of-care CUS allowed the clinician to quickly rule out heart failure in nearly half of suspected cases while easily identifying virus-related interstitial syndrome. The use of CUS appears to be suitable for the rapid bedside investigation of dyspnoea in older patients, particularly in the context of the COVID-19 pandemic.

Impact of a Diagnosis-Centered Antibiotic Stewardship on Incident Clostridioides difficile Infections in Older Inpatients: An Observational Study.

In 2015, a major increase in incident hospital-onset Clostridioides difficile infections (HO-CDI) in a geriatric university hospital led to the implementation of a diagnosis-centered antibiotic stewardship program (ASP). We aimed to evaluate the impact of the ASP on antibiotic consumption and on HO-CDI incidence. The intervention was the arrival of a full-time infectiologist in the acute geriatric unit in May 2015, followed by the implementation of new diagnostic procedures for infections associated with an antibiotic withdrawal policy. Between 2015 and 2018, the ASP was associated with a major reduction in diagnoses for inpatients (23% to 13% for pneumonia, 24% to 13% for urinary tract infection), while median hospital stays and mortality rates remained stable. The reduction in diagnosed bacterial infections was associated with a 45% decrease in antibiotic consumption in the acute geriatric unit. HO-CDI incidence also decreased dramatically from 1.4‱ bed-days to 0.8‱ bed-days in the geriatric rehabilitation unit. The ASP focused on reducing the overdiagnosis of bacterial infections in the acute geriatric unit was successfully associated with both a reduction in antibiotic use and a clear reduction in the incidence of HO-CDI in the geriatric rehabilitation unit.

[Evaluation of the prescription of proton pump inhibitors in persons aged 75years and older in a geriatric acute-care unit]. / Évaluation de la prescription des inhibiteurs de la pompe à protons chez la personne âgée de 75 ans et plus dans un service de gériatrie aiguë.

INTRODUCTION AND OBJECTIVES: Proton pump inhibitors (PPI) are widely prescribed in France and could be responsible for adverse drug reactions especially in elderly persons (EP). In order to reduce the misuse of PPI and the excess cost to the Social Security Agency, the French health authorities (Haute Autorité de santé [HAS]) have published strict guidelines for their prescription. We conducted a study in EP to determine the proportion of PPI prescriptions outside HAS guidelines. METHOD: This was a prospective, single-centre observational study in persons aged≥75 years admitted to a geriatric acute-care unit over a period of 6months. The prevalence of prescriptions for PPI and the proportion of prescriptions outside the guidelines were calculated. The sociodemographic and medical characteristics of EP treated with PPI were studied as were the reasons for the prescription of PPI. RESULTS: Among the 818 patients hospitalized during the study period, 270 were taking PPI on admission (33%). Among these prescriptions, 60% were outside the HAS guidelines. Gastro-oesophageal reflux was the leading indication for PPI (30%), followed by dyspepsia (19%). CONCLUSION: This study confirms the high prevalence of prescriptions for PPI and their misuse. As these drugs are apparently well tolerated, prescriptions are often renewed with no medical re-evaluation.