Use of vitamin K antagonist therapy in geriatrics: a French national survey from the French Society of Geriatrics and Gerontology (SFGG).

OBJECTIVE: We aimed to evaluate the quality and determinants of vitamin K antagonists (VKA) control among very elderly patients in geriatric settings. METHODS: A national cross-sectional survey was conducted among patients aged ≥80 years who were hospitalized in rehabilitation care or institutionalized in a nursing home and who were treated by VKA. Time in therapeutic range (TTR) was computed according to Rosendaal's method. RESULTS: A total of 2,633 patients were included. Mean [± standard deviation (SD)] age was 87.2 ± 4.4 years and 72.9 % were women. The main indication for VKA therapy was atrial fibrillation (AF; 71.4 %). Mean (±SD) TTR was 57.9 ± 40.4 %. After backward logistic regression, poorer VKA control (TTR <50 vs. ≥50 %) was associated with being hospitalized in rehabilitation care [odds ratio (OR)(rehab. vs. nursing home) = 1.41; 95 % CI 1.11-1.80], the indication for VKA treatment (OR(prosthetic heart valve vs. AF) = 4.76; 95 % CI 2.83-8.02), a recent VKA prescription (OR(<1 vs. >12 months) = 1.70; 95 % CI 1.08-2.67), the type of VKA (OR(fluindione vs. warfarin) = 1.22; 95 % CI 1.00-1.49), a history of international normalized ratio >4.5 (OR = 1.50; 95 % CI 1.21-1.84), a history of major bleeding (OR = 1.88; 95 % CI 1.00-3.53), antibiotic use (OR = 1.83; 95 % CI 1.24-2.70), and falls (OR(≥2 falls during the past year vs. <2) = 1.26; 95 % CI 1.01-1.56). CONCLUSION: Overall, VKA control remains insufficient in very old patients. Poorer VKA control was associated with taking VKA for a prosthetic heart valve, a recent VKA prescription, the use of other VKAs than warfarin, a history of overcoagulation and major bleeding, antibiotic use, and falls.

Expert consensus of the French Society of Geriatrics and Gerontology and the French Society of Cardiology on the management of atrial fibrillation in elderly people.

Atrial fibrillation (AF) is a common and serious condition in the elderly. AF affects between 600,000 and one million patients in France, two-thirds of whom are aged above 75 years. AF is a predictive factor for mortality in the elderly and a major risk factor for stroke. Co-morbidities are frequent and worsen the prognosis. The management of AF in the elderly should involve a comprehensive geriatric assessment (CGA), which analyses both medical and psychosocial elements, enabling evaluation of the patient's functional status and social situation and the identification of co-morbidities. The CGA enables the detection of "frailty" using screening tools assessing cognitive function, risk of falls, nutritional status, mood disorders, autonomy and social environment. The objectives of AF treatment in the elderly are to prevent AF complications, particularly stroke, and improve quality of life. Specific precautions for treatment must be taken because of the co-morbidities and age-related changes in pharmacokinetics or pharmacodynamics. Preventing AF complications relies mainly on anticoagulant therapy. Anticoagulants are recommended in patients with AF aged 75 years or above after assessing the bleeding risk using the HEMORR2HAGES or HAS-BLED scores. Novel oral anticoagulants (NOACs) are promising treatments, especially due to a lower risk of intracerebral haemorrhage. However, their prescriptions should take into account renal function (creatinine clearance assessed with Cockcroft formula) and cognitive function (for adherence to treatment). Studies including frail patients in "real life" are necessary to evaluate tolerance of NOACs. Management of AF also involves the treatment of underlying cardiomyopathy and heart rate control rather than a rhythm-control strategy as first-line therapy for elderly patients, especially if they are paucisymptomatic. Antiarrhythmic drugs should be used carefully in elderly patients because of the frequency of metabolic abnormalities and higher risk of drug interactions and bradycardia.

[Expert consensus of the French society of geriatrics and gerontology and the French society of cardiology on the management of atrial fibrillation in elderly people]. / Consensus d'experts de la Société française de gériatrie et gérontologie et de la Société française de cardiologie, sur la prise en charge de la fibrillation atriale du sujet âgé

The prevalence of atrial fibrillation (AF) increase with ageing. In France AF affects between 400,000 to 660,000 people aged 75 years or more. In the elderly, AF is a major risk factor of stroke and a predictive factor for mortality. Comorbidities are frequent and worsen the prognosis of AF. They can be the cause or the consequence of AF and their management is a major therapeutic objective. Comprehensive geriatric assessment (CGA), is required to analyse both medical and psychosocial elements, and to identify co-morbidities and geriatrics syndrome as cognitive disorders, risk of falls, malnutrition, mood disorders, and lack of dependency and social isolation. The objectives of AF treatment in the elderly are to prevent AF complications, particularly stroke, and to improve quality of life. Specific precautions for treatment must be taken because of the co-morbidities and age-related changes in pharmacokinetics or pharmacodynamics. Preventing AF complications relies mainly on anticoagulant therapy. Anticoagulants are recommended in patients with AF aged ≥ 75 years after assessing the bleeding risk using Hemorr2hages or HAS-BLED scores. Novel oral anticoagulants (NOACs) are promising treatments especially due to a lower risk of intracerebral haemorrhage. However, their prescriptions should take into account renal function (creatinine clearance assessed with Cockcroft formula) and cognitive function (for adherence to treatment). Studies including very old patients with several comorbidities in 'real life' are necessary to evaluate tolerance of NOACs in this population. The management of AF also involves the treatment of underlying cardiomyopathy and heart rate control rather than rhythm control strategy as first-line therapy in the elderly.

Consensus of the French Society of Gerontology and Geriatrics and the French Society of Cardiology for the management of coronary artery disease in older adults.

Coronary heart disease is a common and serious condition in patients aged over 80 years. The presenting clinical symptoms are all the more atypical and the prognosis poorer when it occurs in patients with multiple comorbid diseases. The presence of comorbidities dictates the need for a standardized geriatric assessment to screen for the existence of underlying frailty. The available scientific data were obtained during studies that included few subjects aged over 80 years. These recommendations are therefore mainly extrapolated from results obtained in younger populations. The pharmacological management and revascularization strategy for coronary heart disease in octogenarians is basically the same as in younger subjects. Epidemiological studies all concur that available therapies are underutilized despite the fact that this population has a high cardiovascular risk. Specific precautions for use must be respected because of the comorbidities and age-related changes in pharmacokinetics or pharmacodynamics. Generally, the therapeutic strategy in coronary heart disease is based not on the patient's real age, but rather on an individual analysis taking into account the severity of the coronary disease, comorbidities, the risk of drug misadventures, patient life expectancy and quality of life.

[Prescribing beta blockers in elderly patients with heart failure]. / Comment prescrire les bêtabloquants chez l'insuffisant cardiaque âgé?

Beta blockers remain underused in elderly patients with heart failure. Age is not a contraindication to beta blockers. The SENIORS study confirmed that beta blockers are both efficacious and well tolerated in elderly people with heart failure, regardless of their ejection fraction. Because adverse effects may be both more frequent and more serious in the elderly, prescription protocols must be strictly applied. Patients in stable NYHA stages II or III may begin beta blocker treatment, at least 1 month after any decompensation. The initial dose must be as low as possible (1.25 mg/d for bisoprolol and nebivolol). Doses must be increased very progressively and stages longer than 15 days may be necessary. The objective is to reach the target dose (10mg/d for bisoprolol and nebivolol), given the dose-response effect that exists for beta blockers in elderly people with heart failure. In the case of low blood pressure, antihypertensive treatments must be reduced or stopped (for example, nitrate derivatives or calcium channel blockers). A reduction in the dosage of any diuretic dosage and finally of the beta blocker may follow, if necessary. Should bradycardia occur, any anti-bradycardia treatments (such as digoxin or amiodarone) must be reduced or stopped before the beta blocker dosage is reduced.

Effects of Helicobacter pylori infection on gut appetite peptide (leptin, ghrelin) expression in elderly inpatients.

The aim of the study was to investigate the relationship between gastritis and leptin and ghrelin in elderly patients. Patients older than 75 years undergoing an endoscopy were included. We reported data on nutritional status and Helicobacter pylori infection diagnosis (serology, 13C-urea breath test, culture, histology, and polymerase chain reaction on gastric biopsies). Gastric messenger RNA expression of leptin and ghrelin were quantified by real-time polymerase chain reaction. Sixty-two patients were included (84.7 +/- 5.2 years). H. pylori infection was associated with decreased gastric expression of leptin (p = .021), ghrelin (p =.002), and plasma ghrelin levels (p = .018). Atrophy was associated with decreased gastric leptin (p = .007) and ghrelin (p = .02). H. pylori infection correlated negatively with patient energy intake (r = -0.36; p = .001) and body mass index (r = -0.34; p = .018). The negative association between ghrelin and H. pylori infection may be related to a higher prevalence of atrophy and raises the possibility that H. pylori may be contributing to undernutrition in some older people.

[Dural arteriovenous fistula, a rare cause of congestive heart failure in elderly patients]. / Fistule artério-veineuse durale, une cause rare d'insuffisance cardiaque chez la personne agée.

INTRODUCTION: Arteriovenous fistula is a curable cause of high output congestive heart failure. CASE: An 89-year-old woman was hospitalized for acute heart failure. The presence of a continuous murmur in the right carotid artery suggested an arteriovenous fistula. Arteriography showed a dural fistula of the right lateral sinus and confirmed the diagnostic hypothesis. Embolization was ruled out because of the patient's clinical condition, but medical treatment produced a satisfactory outcome. DISCUSSION: Clinical diagnosis of an arteriovenous fistula is based on the characteristic murmur. We report the first case of a dural arteriovenous fistula manifested by congestive heart failure in an elderly patient.

Evaluation of long-term efficacy and acceptability of indapamide SR in elderly hypertensive patients.

OBJECTIVE: To assess the long-term antihypertensive efficacy and acceptability of indapamide SR 1.5 mg in elderly hypertensive patients (> or = 65 years). STUDY DESIGN: Open, 12-month, follow-up study of 444 patients, treated with indapamide SR, who were responders and/or achieved target BP levels following a 3-month, randomised, controlled, double-blind short-term comparison of indapamide SR versus hydrochlorothiazide 25 mg and amlodipine 5 mg. RESULTS: The long-term decrease in systolic blood pressure (SBP)/diastolic blood pressure (DBP) after 12 months follow-up with indapamide SR was -24.0/-13.1 mmHg from baseline (M0). The percentage of patients that achieved target BP levels (DBP < 95 mmHg, SBP < or = 160 mmHg) was 80.1% [84.3% for isolated systolic hypertension (ISH) subgroup], and the response rate (BP < 140/90 mmHg or decrease in supine diastolic BP > or = 10 mmHg or in supine systolic BP > or = 20 mmHg) 81.5%. Blood pressure (BP) remained stable throughout the 12 months follow-up period (M3-M15), whatever the previous treatment received during the 3-month, doubleblind period (M0-M3). Clinical and biological acceptability was good. A low occurrence of withdrawals (7.2%), was reported. CONCLUSION: Over the course of the long-term, 12-month follow-up study, indapamide SR was shown to be an effective and well tolerated antihypertensive therapy, even after a switch from amlodipine or hydrochlorothiazide, in patients aged 65 years-80 years with systolo-diastolic hypertension (SDH) or ISH.

Delirium symptoms and low dietary intake in older inpatients are independent predictors of institutionalization: a 1-year prospective population-based study.

OBJECTIVE: To assess the effects of delirium on the institutionalization rate, taking into account geriatric syndromes and nutritional status. METHODS: This population-based study took place in an acute care unit and included participants older than 75 years, arriving from home and later discharged. Confusion Assessment Method (CAM) symptoms were recorded by the nurses within 24 hours after admission and every 3 days. Delirium was defined using the CAM algorithm, and subsyndromal delirium responded to symptoms not fulfilling the CAM algorithm. These delirium categories were either present at admission (prevalent) or occurred during the hospital stay (incident). Participants were classified as having a low dietary intake when energy intake was at any time lower than 600 kcal/d. Age, sex, known cognitive impairment, weight, functional dependency, and laboratory testing as well as diagnoses were also recorded. Step-by-step backward logistic regression was used to identify predictors of institutionalization. RESULTS: Among 427 patients, 310 (72.6%) were discharged and were compared with 117 (27.4%) participants admitted to an institution. Female sex (odds ratio [OR]: OR 2.15, 95% confidence interval [CI]: CI 1.22-3.78), prevalent delirium (OR 3.19, 95% CI 1.33-7.64), subsyndromal delirium (OR 2.72, 95% CI 1.48-5.01), incident subsyndromal delirium (OR 4.27, 95% CI 2.17-8.39), low dietary intake (OR 2.50, 95% CI 1.35-4.63), and a fall (OR 2.16, 95% CI 1.22-3.84) or a diagnosis of stroke (OR 2.03, 95% CI 1.04-3.94) were independent predictors of institutionalization. CONCLUSIONS: Symptoms of delirium and severe nutritional impairment led patients to geriatric institutions. Therefore, these institutions need to implement policies that address both of these issues.

Detecting Helicobacter pylori infection in hospitalized frail older patients: the challenge.

OBJECTIVES: Helicobacter pylori infection has not been well studied in older people, especially in hospitalized, frail patients. The aim of our study was to evaluate the prevalence of the infection in this population using five H. pylori diagnostic tests. DESIGN: Prospective observational study. SETTING: Geriatric acute care unit of the Department of Geriatrics (Hôpital Xavier Arnozan, Pessac, France). PARTICIPANTS: One hundred seven consecutively hospitalized patients with a diagnostic indication for upper gastrointestinal endoscopy. MEASUREMENTS: Geriatric assessment, information on drug intake, indication/results of gastric endoscopy, and results of H. pylori infection diagnostic tests (culture and histological analysis on biopsy specimens, serology, 13carbon-urea breath test (13C-UBT), detection of H. pylori stool antigens (HpSA)) were assessed for each included patient. RESULTS: Fifty-one patients (47.7%) were H. pylori positive with at least one test. 13C-UBT was more frequently positive than the other four tests, with a significant difference from culture, histological analysis, and HpSA (P <.05). Positive 13C-UBT results were significantly associated with H. pylori presence using histological analysis and neutrophil activity of the antrum and corpus. Antibiotic treatments significantly decreased the positivity rate of all of the tests performed, and severe corpus atrophy decreased the positivity rate of culture, histological analysis, and HpSA. CONCLUSIONS: Almost one-third of the H. pylori-positive patients would have remained undetected without performing the 13C-UBT. The low prevalence of H. pylori detection in these hospitalized, frail patients may be explained by the high frequency of current and previous antibiotic treatments.

Randomized, comparative, double-blind study of amlodipine vs. nicardipine as a treatment of isolated systolic hypertension in the elderly.

A 90-day, multicenter, randomized, double-blind, parallel-group study was conducted to compare the efficacy of amlodipine (once a day) with nicardipine (two to three times a day), in the treatment of isolated systolic hypertension (ISH) in the elderly. Patients (n = 133) aged > or = 60 years, with ISH were randomized to receive either amlodipine 5 mg/day, or nicardipine 60 mg/day (titrated if necessary to 10 mg/day and 100 mg/day, respectively) for 90 days. Efficacy was assessed by measuring office blood pressure (BP), and 24-h ambulatory blood pressure monitoring (ABPM). The two treatments substantially and comparably reduced office systolic blood pressure (SBP) and pulse pressure (PP), and also produced a slight decrease in diastolic blood pressure (DBP). Amlodipine reduced SBP, as assessed by ABPM, to a significantly greater extent than nicardipine. Both treatments were well-tolerated. The sustained effect of amlodipine, compared with nicardipine, was reflected in its significantly greater antihypertensive activity, particularly during the nocturnal period, as assessed by ABPM. The study demonstrates that once a day dose of amlodipine is an effective antihypertensive treatment for elderly ISH patients.