[Treatment of congestive heart failure in older persons and SGLT2 inhibitors - Having your patient's best interests at heart]. / Traitement de l'insuffisance cardiaque chez la personne âgée et inhibiteurs du SGLT2 - En avoir le cœur net.

The treatment and management of heart failure (HF) are constantly evolving. The latest guidelines recommend the use of SGLT2 inhibitors (SGLT2i) as an integral part to treating HF with reduced ejection fraction (< 40%). However, given that the patients included in these trials do not reflect the heterogeneity of the health of many elderly patients, we recommend basing the therapeutic decision on the patient's state of frailty. If a SGLT2i treatment at a standard dose (10 mg 1x/day) is recommended for robust patients, we suggest initiating treatment at 5 mg 1x/day for vulnerable patients, and then after 1 month increasing the dose to 10 mg 1x/day. Finally, for dependent patients, we recommend therapeutic abstention in the absence of sufficient scientific evidence.

La prise en charge de l'insuffisance cardiaque (IC) est en constante évolution. Les dernières recommandations préconisent l'utilisation des inhibiteurs du SGLT2 (iSGLT2) pour le traitement de l'IC à fraction d'éjection réduite (< 40%). Cependant, les populations des études ne reflètent pas l'hétérogénéité de la population âgée en termes de santé et nous proposons de baser la décision thérapeutique selon la Clinical Frailty Scale : si, pour les patients robustes, un traitement par iSGLT2 à dose standard (10 mg 1 x/jour) est préconisé, nous proposons, pour les patients vulnérables, d'initier le traitement à 5 mg 1 x/jour, puis d'augmenter à 10 mg 1 x/jour après 1 mois. Finalement, pour les patients dépendants, nous recommandons une abstention thérapeutique en l'absence d'évidences scientifiques suffisantes.

[Geriatrics]. / Gériatrie.

Sleeping enough is associated with a reduced risk of mortality and dementia. New evidence support regular physical exercise, including at home, as a corner stone intervention to prevent falls and fractures. In contrast, supplementation with high doses of vitamin D is ineffective and even deleterious in this indication and a routine screening in asymptomatic adults is not recommended. Several studies illustrate our difficulties in prescribing and deprescribing in frail older patients and a study suggests that statins in cardiovascular primary prevention should considered only when a patient's life expectancy exceeds 2.5 years. Finally, several studies have fueled the debate about screening for hearing impairment.

Dormir ni trop ni trop peu est associé à une réduction du risque de mortalité et de déclin cognitif. De nouvelles études confirment que l'exercice physique régulier, y compris à domicile, constitue la clé de voûte de la prévention des chutes et des fractures. Par contre, la supplémentation par de hautes doses de vitamine D n'est pas efficace, voire délétère, dans cette indication et le dépistage systématique d'un déficit n'est pas recommandé chez les patients adultes asymptomatiques. Plusieurs études illustrent nos difficultés à prescrire et déprescrire, chez les patients âgés fragiles, et une étude suggère qu'un traitement de statines en prévention cardiovasculaire primaire ne se justifie que si l'espérance de vie du patient dépasse 2,5 ans. Finalement, plusieurs études sont venues nourrir le débat sur le dépistage de la presbyacousie.

[To D or not to D ? Why and how to treat vitamin D deficiency in older patients]. / « To D or not to D ¼ : pourquoi et comment traiter l'hypovitaminose D chez les personnes âgées.

Vitamin D deficiency is so frequent in older patients (aged 65 years and older) that the international consensus does not recommend routine vitamin D measurement. Assessment of overall health status is a cornerstone before considering vitamin D supplementation, as the effect of vitamin D supplementation has only been demonstrated in vulnerable or dependent but not for robust older patients. The effect of the different modalities of oral vitamin D supplementation are equivalent : 800-1'200 IU/day, 10'000 IU/week or 30'000-50'000 IU/month. Monitoring of vitamin D blood level monitoring is not necessary because of a large therapeutic margin. In the presence of osteoporosis, a dietary or supplementation intake of 1'200 mg per day of calcium should be added.

L'hypovitaminose D est très fréquente chez les personnes âgées (65 ans et plus), à tel point que le consensus international est de ne pas doser la vitamine D en routine. L'évaluation de l'état de santé global est primordiale avant d'envisager une supplémentation en vitamine D, son effet ayant été démontré seulement chez les personnes âgées vulnérables ou dépendantes, mais pas chez les robustes. L'efficacité des modalités de supplémentation en vitamine D per os sont équivalentes : 800-1200 UI/jour, 10 000 UI/semaine ou 30 000-50 000 UI/mois. Un monitoring du taux sanguin de vitamine D n'est pas nécessaire en raison d'une large marge thérapeutique. En présence d'une ostéoporose, cette supplémentation devrait être complétée par un apport alimentaire ou une supplémentation de 1200 mg de calcium par jour.

Impact of an early geriatric rehabilitation program in acutely hospitalised vulnerable patients: a real-life study in an ACE unit in Switzerland.

INTRODUCTION: Early geriatric rehabilitation programs are potential means to prevent acute hospitalisation-associated functional decline. METHODS: The objectives were to measure the impact of an interdisciplinary rehabilitation program on patients' administrative in hospital data and on functional trajectories. With a before-and-after design, we compared all patients admitted from January to August 2018 into the Acute Care for Elders (ACE) unit of an Academic hospital in Switzerland who received this type of program to those admitted during the same period in 2016 and 2017. We considered vulnerable patients aged 75 or older. Functional independency level was assessed at baseline, admission, and discharge according to Katz's basic activities daily living (BADL). RESULTS: In total, 378/1,073 patients (mean age 86.6 ± 6.4; 74.6% women; 84% admitted from the emergency department) were prospectively admitted into the ACE unit in 2018. With an adherence rate of 74.0% to functional therapies and compared to the prior years, the program reduced transfers to rehabilitation settings (28.5 vs. 24.3%, p=0.04) and increased direct discharges to home (46.8 vs. 42.4%, p=0.04). Rates of early-unplanned readmission were similar. Between admission to discharge, 89.9% of the patients engaged in the program remained functionally stable or enhanced. Whatever the BADL score at the admission, 46.5% improved their status for at least one BADL. Even though no clinical determinant was identified, patients who engaged ≥ 5 sessions of functional therapy per week were more likely to improve their functional level (OR = 3.05; 95% CI 1.76-5.27). CONCLUSION: This real-life study demonstrates arguments to implement early interdisciplinary rehabilitation program in ACE units in particular to prevent functional decline in vulnerable patients. These findings support consideration regarding the interest of switching from the traditional disease-centred approach in acute care for older patients to a modern one, that also put the emphasis on maintaining functional capacities.