Anticholinergic burden and poor oral health are associated with frailty in geriatric patients undergoing inpatient rehabilitation: A cross-sectional study.

BACKGROUND: Poor oral health is known to be associated with frailty in geriatric populations. Recent exposure to anticholinergic medications is responsible for features of poor oral health. Anticholinergic medications pose a cumulative risk for frailty. METHODS: We studied 115 geriatric inpatients (aged >65 years and recruited over a 3-month period from October to December 2017). Patients who were severely agitated, cognitively impaired, from a non-English speaking background and with severe sensory impairment were excluded. Frailty and oral health were assessed using the Reported Edmonton Frailty Scale and the Oral Health Assessment Test, respectively. Exposure to anticholinergic medications was assessed using the Anticholinergic Burden Scale. RESULTS: The mean age was 80 (range from 66 to 101). Only 44 patients (38.3%) were not exposed to any anticholinergic medication. Nearly two-thirds of patients were taking anticholinergic medications, with 25% classified as having a high anticholinergic burden (ACB ≥ 4). Approximately one-third of severely frail patients were exposed to a high anticholinergic burden. Patients with a high anticholinergic burden were more than twice as likely to have severe frailty (OR 2.21; 95% confidence interval 1.05-4.6). Poor oral health was associated with frailty (OR 1.24; 95% CI 1.02-1.49). CONCLUSION: High anticholinergic burden was found to be a risk marker for severe frailty independent of its effect on oral health. Poor oral health was associated with all levels of frailty. This study highlights a need for a review of medications with anticholinergic properties in older patients. Further research should be directed at whether deprescribing could prevent poor oral health or slow the progression of frailty.

Left ventricular contractile reserve as a determinant of adverse clinical outcomes: a systematic review.

An abnormal left ventricular contractile reserve is often seen in patients undergoing stress echocardiogram and may indicate the presence of obstructive coronary artery disease. The techniques and indexes used to identify abnormal left ventricular contractile response and its prognostic value in the absence of known causes has not been well studied. To describe the characteristics and clinical outcomes associated with an abnormal left ventricular contractile response, we performed a systematic review that identified 27 eligible studies. A diverse range of indices were utilised to measure left ventricular contractile reserve, most commonly Δleft ventricular ejection fraction in 11 studies. Dobutamine stress echocardiogram was the most commonly performed modality (19 studies) followed by exercise stress echocardiogram (4 studies), dipyridamole stress echocardiogram (2 studies), invasive hemodynamic measurement (1 study) and dobutamine stress magnetic resonance imaging (1 study). All but one study demonstrated a significant association between the absence of left ventricular contractile reserve and increased rate of cardiovascular events, cardiac death and all-cause mortality.

Frailty, oral health and nutrition in geriatrics inpatients: A cross-sectional study.

BACKGROUND: Poor nutritional status is a risk factor for the development of frailty. Likewise, oral health is independently associated with nutrition. The potential association between oral health and frailty in hospitalised elderly adults has, however, not previously been investigated. OBJECTIVE: To investigate the relationship between oral health and frailty in hospitalised elderly adults and to identify the predictors of frailty. METHOD: A cross-sectional study of 168 geriatric inpatients >65 years old was performed from August to December 2016. Patients of non-English speaking background, with impaired cognition (MMSE <24), severe hearing or visual impairment or active delirium were excluded. Oral health, nutrition and frailty were assessed using previously validated tools, namely the Geriatric Oral Health Assessment Index (GOHAI), Mini Nutrition Assessment (MNA) and Reported Edmonton Frailty Scale (REFS). Other data collected included demographics, co-morbidities, level of education and smoking/alcohol history. RESULTS: On univariate analysis, the REFS score decreased with better nutritional status/higher MNA (P < 0.001) and better self-reported oral health/higher GOHAI (P = 0.023). Nutritional status accounted for 17% of variability in frailty assessment. On multivariate analysis, co-morbidities (P < 0.001), MNA (P < 0.001) and living in residential care (P < 0.001) were independent predictors of frailty. After adjusting for nutrition and co-morbidities, self-reported oral health was found to have an independent negative association with frailty (P = 0.019). CONCLUSION: Poor self-reported oral health was found to be independently associated with frailty. Further research should be directed at whether interventions to maintain good oral health can prevent or slow the progression of frailty.

Predictors of acute hospital mortality and length of stay in patients with new-onset atrial fibrillation: a first-hand experience from a medical emergency team response provider.

BACKGROUND: Atrial fibrillation (AF) occurs frequently following cardiothoracic surgery and treatment decisions are informed by evidence-based clinical guidelines. Outside this setting there are few data to guide clinical management. AIM: To describe the characteristics, management and outcomes of hospitalised adult patients with new-onset AF. METHODS: The medical emergency team (MET) database was utilised to identify patients who had a 'MET call' activated for tachycardia between 2015 and 2016. Patients with sinus tachycardia, pre-existing AF/atrial flutter or other known tachyarrhythmia were excluded. Primary outcomes were length of hospital stay and in-hospital mortality. RESULTS: New-onset AF was identified in 137 patients: 68 medically managed; 38 non-cardiothoracic post-operative; and 31 cardiothoracic post-operative. Mean age was 74 ± 11.6 years and 72 (53%) were male. Of 79 patients who underwent echocardiography, 80% had left atrial dilatation and 14% had reduced left ventricular ejection fraction (LVEF). Mean length of stay (LOS) was 12 days and in-hospital mortality rate was 11%. On multivariable analysis, the odds of death during acute hospitalisation was 7.4 times higher in patients with heart failure with reduced LVEF (odds ratio 7.4, 95% confidence interval (CI) 1.23-44.8, P = 0.028). Length of acute hospital stay increased by 36% if the duration of AF was longer than 48 h (beta coefficient 0.36, 95% CI -0.015 to 0.74, P = 0.059). CONCLUSION: Left ventricular systolic dysfunction in hospitalised patients with new-onset AF is associated with increased all-cause mortality whereas lower serum potassium levels are associated with an increased LOS. A prospective study is planned to compare outcomes based on in-hospital treatment strategies.

A Small Change Can Make a Big Difference: A Lesson from Evolocumab.

BACKGROUND: Evolocumab is an expensive proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor which has been shown to significantly improve cardiovascular outcomes in high risk patients. METHODS: This is a case study describing a stepwise approach to "PCSK9 inhibitor non-response" in a patient with familial hypercholesterolaemia. There are a few described pathophysiological mechanisms for "PCSK9 inhibitor non-response" including homozygous LDL-C receptor-negative mutations and alteration in the binding site of PCSK9 inhibitors. RESULTS: We report the case of a 41-year-old woman with familial hypercholesterolaemia and premature cardiovascular disease, who was non-responsive to the action of PCSK9 inhibitor solely due to the incorrect subcutaneous injection technique. CONCLUSIONS: This case study highlights the importance of reviewing the accuracy of SC injection technique in patients with minimal or no response to PCSK9 inhibitors prior to proceeding to costly genetic testing.

The effect of combined ezetimibe and statin therapy versus statin therapy alone on coronary plaque volume assessed by intravascular ultrasound: A systematic review and meta-analysis.

BACKGROUND: Current guidelines recommend an intensive lipid-lowering therapy to achieve the low-density lipoprotein cholesterol (LDL-C) target in patients with high risk of cardiovascular disease. Former studies suggested adding ezetimibe to statin therapy in the above setting may promote plaque changes; however, this effect has not been consistently reported. METHODS: Electronic searches were performed in MEDLINE, EMBASE, and Cochrane library on November 30, 2017 to identify prospective trials assessing the effects of combined ezetimibe and statin therapy versus statin therapy alone on atheroma volume using intravascular ultrasound. The effect size between treatment groups within individual studies was assessed by weighted mean difference (MD) using a random-effects model. RESULTS: Eight studies were obtained for systematic review and 6 of them compromising total of 583 subjects that meet the criteria were meta-analyzed. There was a significant reduction from baseline to follow-up in total atheroma volume with an MD of -3.71 mm3 (95% confidence interval: -5.98 to -1.44, P < .001), whereas analysis for percent atheroma volume demonstrated weighted MD of - 0.77% (-1.68 to 0.14, P = .10). A substantial decrease in LDL-C was observed with MD -16.75 mg/dL (-20.89 to -12.60, P < .00001). CONCLUSION: The addition of ezetimibe to statin therapy is effective in reducing total atheroma volume assessed by intravascular ultrasound and also resulted in effective reduction of plasma LDL-C levels.