Therapy For Older Adults Research Articles

Androgen effects on skeletal muscle: implications for the development and management of frailty

Androgens have potent anabolic effects on skeletal muscle and decline with age in parallel to losses in muscle mass and strength. This loss of muscle mass and function, known as sarcopenia, is the central event in development of frailty, the vulnerable health status that presages adverse outcomes and rapid functional decline in older adults. The potential role of falling androgen levels in the development of frailty and their utility as function promoting therapies in older men has therefore attracted considerable attention. This review summarizes current concepts and definitions in muscle ageing, sarcopenia and frailty, and evaluates recent developments in the study of androgens and frailty. Current evidence from observational and interventional studies strongly supports an effect of androgens on muscle mass in ageing men, but effects on muscle strength and particularly physical function have been less clear. Androgen treatment has been generally well–tolerated in studies of older men, but concerns remain over higher dose treatments and use in populations with high cardiovascular risk. The first trials of selective androgen receptor modulators (SARMs) suggest similar effects on muscle mass and function to traditional androgen therapies in older adults. Important future directions include the use of these agents in combination with exercise training to promote functional ability across different populations of older adults, as well as more focus on the relationships between concurrent changes in hormone levels, body composition and physical function in observational studies.

Fecal Transplantation for Recurrent Clostridium difficile Infection in Older Adults: A Review

Recurrent Clostridium difficile infection (CDI) is a common nosocomial infection that has a large effect on morbidity and quality of life in older adults in hospitals and long-term care facilities. Because antibiotics are often unsuccessful in curing this disease, fecal transplantation has emerged as a second-line therapy for treatment of recurrent CDI. A comprehensive literature search of PubMed, Embase, and Web of Science regarding fecal transplantation for CDI was performed to further evaluate the efficacy and side effects of this promising therapy in older adults. Data were extracted from 10 published articles from 1984 to the present that met inclusion criteria, including nine open-label reports and one randomized controlled trial. Baseline characteristics and outcomes of individuals undergoing fecal transplantation and effects of fecal transplantation on the fecal microflora were reviewed. Methods of fecal transplantation and donor selection were reviewed. Fecal transplantation was performed in 115 individuals aged 60 to 101, with a female predominance. CDI cure was achieved in 103 (89.6%) individuals over a follow-up period of 2 months to 5 years (mean 5.9 months). There was no significant difference in cure rate between older and younger participants in included studies. Most failed transplantation occurred in individuals infected with the aggressive NAP1/027 strain of C. difficile. Microbiological studies of fecal biodiversity before and after fecal transplantation demonstrated greater bacterial diversity and shift in flora species to resemble donor flora after transplantation that correlated with clinical remission. Fecal transplantation provides a safe and durable cure for older adults with recurrent CDI.

Safety and blood pressure trajectory of short-term withdrawal of antihypertensive medications in older adults: Experience from a clinical trial sample

BackgroundThe short-term safety of and blood pressure changes after withdrawing hypertension treatment in older adults in preparation for clinical trials have not been well established. MethodsParticipants were enrolled in a clinical trial and antihypertensive medications were tapered over 3 weeks (week 1: reduction by 25%–50%; week 2: 50%–75%, week 3: off). Blood pressure was measured at the initial visit and after stopping all antihypertensive therapy (personnel) and twice a day during the taper phase (provided monitor). Trend analyses and linear models were used to assess changes in blood pressure. ResultsAll participants (n = 53, mean age = 71 years, total of 1158 readings) successfully tapered their medications with no symptoms. Only 2% of the readings exceeded 180/100 mm Hg, but none were consecutive. Blood pressure gradually increased with an overall increase of 12/6 mm Hg, 95% confidence interval (4/1, 21/11). The daily increase in blood pressure was 0.2 mm Hg (standard error = 0.1) in both the systolic and diastolic blood pressure. Increases in systolic and diastolic blood pressure were comparable for all antihypertensive classes (P > .05 for all). ConclusionShort-term (<3-4 weeks) withdrawal of antihypertensive therapy in older adults with hypertension is safe and is associated with mild increases in blood pressure.

Resynchronization: Considering Device‐Based Cardiac Therapy in Older Adults

Cardiac resynchronization therapy (CRT) is a device-based treatment available to select individuals with systolic heart failure (HF), a large proportion of whom are aged 65 and older. As the field of CRT advances, together with shifting demographics and expanded indications for implantation, there is a need for practitioners caring for older adults to understand what is and is not known about the use of CRT specifically in this population. Clinical trials demonstrating benefits for severe and mild HF have uncertain generalizability to older adults. Other studies demonstrate that device-related complications may be more common with CRT than with simpler devices and more common in older adults. CRT clinical trials also may not adequately capture outcomes and concerns specific to older adults, including quality of life and end-of-life care experiences. Informed decision-making by clinicians, policy-makers, and patients will require greater understanding of the use and outcomes of CRT in older persons.

Nutritional Status and Drug Therapy in Older Adults

The aging process is characterized by a high level of complexity with a progressive decline in several physiological systems coexisting with multiple chronic diseases (comorbidity), presence of cognitive and functional impairment and geriatric syndromes. Use of multiple drugs and problems in nutritional status are relevant components of this complex spectrum. Nutritional status may influence the pharmacokinetic and pharmacodynamic of many drugs, conversely drugs can impair nutrition by causing adverse drug reactions such as nausea and loss of appetite. The present article describes potential interactions between nutritional status and drug use in the elderly. The role of nutritional status in the pharmacokinetic of drugs (including absorption, distribution, metabolism and elimination) is reviewed and most relevant food drugs interactions are assessed. Malnutrition and nutritional problems are common conditions in older adults. Multiple chronic disease, inflammation, cognitive and functional impairment, geriatric syndromes (including delirium, falls or chronic pain) and drug use (i.e. polypharmacy, adverse drug reactions) may play a role in the onset of malnutrition and nutritional problems. In particular, drugs and nutrition are closely connected. Nutritional status may influence the pharmacokinetic and pharmacodynamic of many drugs, conversely, drugs can impair nutrition by causing adverse drug reactions such as nausea and loss of appetite. The present article will assess potential interactions between nutritional status and drug use in the elderly.

What is an appropriate blood pressure goal for the elderly: review of recent studies and practical recommendations

Hypertension is common in the elderly, and isolated systolic hypertension is responsible for the majority of hypertension in this population. Hypertension in the elderly can be attributed to numerous structural and functional changes to the vasculature that develop with advancing age. Increased systolic blood pressure is associated with adverse outcomes, including stroke, cardiovascular disease, and death. Some studies demonstrate an inverse relationship between cardiovascular outcomes and diastolic blood pressure whereas other studies show a J-shaped or U-shaped association between blood pressure and outcomes. The complex J-shaped association coupled with the unique characteristics of elderly patients have led to much debate and confusion regarding the treatment of hypertension in this population. Clinical trials indicate a benefit to therapy in older adults, and there appears to be no age threshold above which antihypertensive therapy should be withheld. Treatment of hypertension in elderly patients is further complicated by increased susceptibility to brain hypoperfusion with orthostatic hypotension as well as the risk of drug–drug interactions. We recommend a systolic blood pressure goal of <140 mmHg in patients less than 80 years of age and a systolic blood pressure goal of 140–150 mmHg in patients 80 years of age or older. Reduction of blood pressure is probably more important than the specific agent used and initiation of drug therapy with an angiotensin converting enzyme inhibitor, angiotensin receptor blocker, calcium channel blocker, or diuretic are all reasonable options, and the decision should be individualized based on underlying comorbidities.

2114 – A pilot study on promoting sense of coherence through person-centered therapy in older adults

Older adults’ sense of coherence (SOC) is often challenged by changes in later adulthood. Therefore, this study aims to explore if a brief eight-session individual person-centered therapy (PCT) intervention on older adults can promote their SOC, as compared with a control group (waiting list). We posited that participants and randomized to PCT would report improvements in SOC from pre- to post-intervention compared to those in waiting list. The Sense of Coherence Scale (SOCS).and demographics were assessed at the baseline (t 1 ), post-treatment (t 2 ) and at the 12-month follow-up (t 3 ), in a group of 87 participants between 65-86 years ( M =71.9 SD =4.77). Results indicated that participants in PCT evidenced greater improvements as to their SOC (31.4%) than those in waiting list (2.3%). Both at the post-intervention, and at follow-up, participants who underwent PCT had a significantly higher SOC (M=4.76, SD=.524). In addition, results revealed no significant between group differences in any socio-demographic variable ( P's >.05) in t 1 , t 2 and t 3 . Changes in SOC were positive and maintained, thus, findings suggest that PCT is favorable to enhancing SOC. In this context, PCT is also a personal resource to promote SOC. Moreover, since SOC is shown to be associated with healthrelated well-being among older populations, SOC development in old age should be focused.

Antidepressant Use in Underweight Older Adults

Mirtazapine is an antidepressant approved for the treatment of major depressive disorder. It has been reported to also stimulate appetite and/or increase body weight, which may be beneficial in certain patient populations such as the elderly. To evaluate the use of mirtazapine and other antidepressants in underweight older adults, a retrospective chart review of patients (60 years of age or older and with a body mass index < 22 kg/m2) who were prescribed an antidepressant during hospitalization was conducted over a six-month period at a large university teaching hospital. Results demonstrated that underweight older patients were more likely to receive mirtazapine than any other antidepressant, prompting a systematic literature review to assess its potential role in appetite stimulation and weight gain. In addition, educational inservice training for health care professionals within the institution was provided to discuss the management of weight loss and appetite suppression in the elderly as well as the potential benefits and risks of antidepressant therapy in older adults.

Aspirin Use After Diagnosis Improves Survival in Older Adults with Colon Cancer: A Retrospective Cohort Study

To assess survival in relation to aspirin use after diagnosis in older adults with colon cancer. Subgroup analysis of a previously published cohort and retrospective study. Individuals registered in the Eindhoven Cancer Registry (ECR) between 1998 and 2007, linked to prescriptions of low-dose aspirin (80 mg) registered in a community pharmacy database. Five hundred thirty-six individuals aged 70 and older diagnosed with colon cancer with or without aspirin use after diagnosis. Survival was analyzed with user status as a time-dependent covariate. Multivariate Poisson regression survival models were used to study the effect of aspirin on overall survival. One hundred seven participants (20.0%) started aspirin after being diagnosed with colon cancer; 429 (80.0%) were not prescribed aspirin. Three hundred thirty-nine participants (63.2%) had died by the end of follow-up. Aspirin use after diagnosis was associated with longer overall survival (rate ratio (RR) = 0.51, 95% confidence interval (CI) = 0.38-0.70, P < .001). Multivariate proportional hazards regression analysis revealed that aspirin use was associated with longer overall survival (adjusted RR = 0.59, 95% CI = 0.44-0.81, P = .001). Aspirin use after the diagnosis of colon cancer in older adults was associated with longer survival. Low-dose aspirin could be used as an effective adjuvant therapy in older adults with colon cancer.

Predialyis Nephrology Care of Older Individuals Approaching End-Stage Renal Disease

Many older patients with advanced CKD approaching ESRD do not receive timely nephrology care, although data suggest that the situation may be improving. In 2005-2008, 43% of older patients who initiated renal replacement therapy had experienced an outpatient nephrologist consultation more than 1 year before starting treatment. Earlier consultation with a nephrologist has been found to provide better access to peritoneal dialysis and kidney transplantation, better preparation for the chosen dialytic modality, and improved survival after start of dialysis or receipt of a kidney transplant. Recent data suggest that older individuals are less likely to receive treatment for ESRD compared with younger individuals in whom almost all receive dialysis treatment or transplantation. Little is known about the role nephrologists play in the decision whether to initiate dialysis or choose a conservative route among older adults with ESRD. Defining the appropriate role and involvement of nephrologists in the decision about initiating renal replacement therapy in older adults seems ripe for further investigation and discussion.

Treatment of Headache in the Elderly

Opinion statementMost primary headaches in the elderly are similar to those in younger patients (tension, migraine, and cluster), but there are some differences, such as late-life migraine accompaniments and hypnic headaches. Although migraine in younger persons usually presents with headache, migraine in older persons may initially appear with visual or sensory phenomena, instead of headache (“migraine accompaniments”). Hypnic headaches awaken patients from sleep, are short-lived, and occur only in the elderly. The probability of secondary headache increases steadily with age. Secondary headaches include those associated with temporal arteritis, trigeminal neuralgia, sleep apnea, post- herpetic neuralgia, cervical spondylosis, subarachnoid hemorrhage, intracerebral hemorrhage, intracranial neoplasm, and post-concussive syndrome. Certain rescue treatments for migraine headache in younger individuals (triptans or dihydroergotamine, for example) should not be used in elderly patients because of the risk of coronary artery disease. Naproxen and hydroxyzine are commonly used oral rescue therapies for older adults who have migraine or tension headaches. Intravenous magnesium, valproic acid, and metoclopramide are all effective rescue therapies for severe headaches in the emergency room setting. Some effective prophylactic agents for migraine in younger patients (amitriptyline and doxepin) are not usually recommended for older individuals because of the risks of cognitive impairment, urinary retention, and cardiac arrhythmia. For these reasons, the recommended oral preventive agents for migraine in older adults include divalproex sodium, topiramate, metoprolol, and propranolol. Oral agents that can prevent hypnic headaches include caffeine and lithium. Cough headaches respond to indomethacin or acetazolamide.

Dehydroepiandrosterone replacement therapy in older adults improves indices of arterial stiffness

Serum dehydroepiandrosterone (DHEA) concentrations decrease approximately 80% between ages 25 and 75 year. Aging also results in an increase in arterial stiffness, which is an independent predictor of cardiovascular disease (CVD) risk and mortality. Therefore, it is conceivable that DHEA replacement in older adults could reduce arterial stiffness. We sought to determine whether DHEA replacement therapy in older adults reduces carotid augmentation index (AI) and carotid-femoral pulse wave velocity (PWV) as indices of arterial stiffness. A randomized, double-blind trial was conducted to study the effects of 50 mg day(-1) DHEA replacement on AI (n = 92) and PWV (n = 51) in women and men aged 65-75 year. Inflammatory cytokines and sex hormones were measured in fasting serum. AI decreased in the DHEA group, but not in the placebo group (difference between groups, -6 ± 2 AI units, P = 0.002). Pulse wave velocity also decreased (difference between groups, -3.5 ± 1.0 m s(-1), P = 0.001); however, after adjusting for baseline values, the between-group comparison became nonsignificant (P = 0.20). The reductions in AI and PWV were accompanied by decreases in inflammatory cytokines (tumor necrosis factor α and IL-6, P < 0.05) and correlated with increases in serum DHEAS (r = -0.31 and -0.37, respectively, P < 0.05). The reductions in AI also correlated with free testosterone index (r = -0.23, P = 0.03). In conclusion, DHEA replacement in elderly men and women improves indices of arterial stiffness. Arterial stiffness increases with age and is an independent risk factor for CVD. Therefore, the improvements observed in this study suggest that DHEA replacement might partly reverse arterial aging and reduce CVD risk.

Midodrine hydrochloride in the management of older adults with neurocardiogenic syncope and orthostatic hypotension: A prospective observational study

BackgroundMidodrine hydrochloride has been shown to be effective in the management of syncope in adults with reflex syncope, orthostatic hypotension and orthostatic intolerance syndromes; however, its use, tolerability and side effects have not been monitored specifically in the older old, particularly not over a prolonged period of time. ObjectivesWe aim to document changes in patients’ symptoms, drug dosages employed and adverse drug reactions to midodrine therapy in older adults with a diagnosis of neurocardiogenic syncope assessed and managed at a specialist falls and syncope outpatient unit. MethodsProspective observational study of 135 consecutive subjects with a mean age of 84 years started on midodrine after comprehensive geriatric assessment, structured falls evaluation, positive tilt table testing (TT) or a mixed/vasodepressor response to carotid sinus massage (CSM). ResultsNinety-seven individuals (71%) commenced on midodrine treatment and followed up for a mean of 2.7 years, reported either significant improvement or abolition of symptoms across all TT/CSM diagnosis. Forty-nine percent of individuals achieved sustained clinical improvement after an initial dosage of 2.5mg three times per day and only four patients required dosages above 7.5mg three times daily. One hundred and one individuals (75%) continued midodrine until the end of the monitoring period, and although 19 subjects developed adverse drug reactions, most were minor and only six resulted in drug withdrawal. ConclusionsMidodrine hydrochloride appears to be safe and well tolerated in older adults and should be considered, independent of age, in the management of patients with symptomatic orthostatic hypotension, vasovagal syncope and vasodepressor or mixed carotid sinus syndrome. This observation requires further confirmation by larger multicenter randomised control studies.

Clinical pharmacology confounders in older adults

Major advances produced by healthcare research have resulted in an increasing number of drugs that may be used to modify disease expression and improve quality of life. These discoveries have been used by clinical pharmacologists as a basis to identify new drug candidates and to develop strategies for their optimal delivery to maximize benefit while simultaneously minimizing adverse events. Unfortunately, many of these studies do not include sufficient older persons in whom most of these drug therapy interventions are likely to apply. This article examines selected physiological, pathological and healthcare interventional changes with age that impact clinical drug studies and the decision to use drugs as therapy in older adults. Clinical examples are provided that illustrate confounders to the accomplishment of an ideal outcome, the improved quality of life that remains for this population.

Hearing Loss in Older Adults

Hearing Loss in Older Adults

PREVENTING FRAILTY IN OBESE OLDER ADULTS

PREVENTING FRAILTY IN OBESE OLDER ADULTS

Phase II trial of vorinostat and gemtuzumab ozogamicin as induction and post-remission therapy in older adults with previously untreated acute myeloid leukemia

Histone deacetylase inhibitors such as vorinostat enhance gemtuzumab ozogamicin efficacy in vitro. We, therefore, investigated vorinostat+gemtuzumab ozogamicin for adults aged 60 years and over with untreated acute myeloid leukemia. We stratified patients into 2 groups (group 1: patients aged ≥ 70 years and performance status 2-3; group 2: aged 60-69 years with performance status 0-3 or aged ≥ 70 years and performance status 0-1). Responses were monitored separately in group 2 patients with normal or favorable cytogenetics (group 2A) and other cytogenetics (group 2B). Among 31 patients, 6 (19.4%) achieved complete remission, and one (3.2%) achieved complete remission with incomplete platelet recovery; these patients had a higher median overall survival than non-responders (553 vs. 131 days, P = 0.0026). Response rates were: group 1, one of 10 (10.0%); group 2A, 6 of 13 (46.2%); and group 2B, none of 8 (0%). These data indicate that vorinostat+gemtuzumab ozogamicin has activity that is mostly confined to patients with normal karyotype disease. ClinicalTrial.gov: NCT00673153.

Initiation of Statin Therapy: Are There Age Limits?

Cardiovascular disease (CVD) is the leading cause of death, with a higher prevalence in older adults who form an increasing proportion of the population of the United States. Statin treatment reduces cardiovascular morbidity and mortality in middle-aged adults. However, few studies have included older individuals, particularly ages 80years or older. We review recent publications regarding primary and secondary prevention of CVD with statin therapy in older adults. Risk scores and their limitations in this population are discussed. The association of adverse effects with intensive doses of statin and their interactions with other drugs may be more problematic in older adults. Statin therapy appears cost-effective for individuals with higher CVD risk but this is dependent on the assumptions used. Evidence remains limited regarding the overall benefit of starting statin therapy in adults ages 80years and older; thus, clinical judgment remains necessary in making this decision.

Garden Walking and Art Therapy for Depression in Older Adults: A Pilot Study

The purpose of this pilot study was to compare garden walking (either alone or guided) with art therapy in older adults with depression. Depression was measured using the Geriatric Depression Scale (GDS) and stories of sadness/joy. Prior to the intervention, 47% of participants had depression scores in the severe range and 53% in the mild range. At the end of the intervention, none of the participants had scores in the severe range, 89% had scores in the mild range, and 11% had scores in the normal range. Results of the GDS data using repeated measures analysis of variance indicated significant decreases in depression for all three groups from pretest to posttest. All participants, regardless of group assignment, had a lower percentage of negative-emotion word use and a higher percentage of positive-emotion word use over time. This study provides evidence for nurses wishing to guide older adults in safe, easy, and inexpensive ways to reduce depression.

Anticoagulation Therapy in Older Adults Newly Diagnosed with Atrial Fibrillation

Atrial fibrillation (AF) is the most common chronic arrhythmia and the most serious heart rhythm irregularity in individuals older than 70. It is usually not life threatening in and of itself, but it can lead to serious medical problems, including stroke, additional heart rhythm problems, and heart failure. Symptoms of AF vary considerably. Some patients are asymptomatic and have a self-limiting arrhythmia of short duration that converts to normal sinus without any intervention. Symptomatic patients may experience minor palpitations, severe palpitations, or even more vague symptoms such as lightheadedness, shortness of breath, or fatigue. More serious symptoms, such as syncope, new or worsening heart failure, or a cerebral vascular accident, may occur. The initial goals of treatment include controlling ventricular rate and addressing anticoagulation status. New guidelines help clinicians effectively manage anticoagulant therapy for older adults newly diagnosed with AF.