Statins and Selective Serotonin Reuptake Inhibitors are Associated with Longer Survival in Nursing Home Residents.

BACKGROUND: Statins and selective serotonin reuptake inhibitors (SSRIs) have beneficial effects on health outcomes in the general population. Their effect on survival in debilitated nursing home residents is unknown. OBJECTIVES: To assess the relationships between statins, SSRIs, and survival of nursing home residents. METHODS: Baseline patient characteristics, including chronic medications, were recorded. The association of 5-year survival with different variables was analyzed. A sub-group analysis of survival was performed according to baseline treatment with statins and/or SSRIs. RESULTS: The study comprised 993 residents from 6 nursing homes. Of them, 285 were males (29%), 750 (75%) were fully dependent, and 243 (25%) were mobile demented. Mean age was 85 ± 7.6 years (range 65-108). After 5 years follow-up, the mortality rate was 81%. Analysis by sub-groups showed longer survival among older adults treated with only statins (hazard ratio [HR] for death 0.68, 95% confidence intervals [95%CI] 0.49-0.94) or only SSRIs (HR 0.6, 95%CI 0.45-0.81), with the longest survival among those taking both statins and SSRIs (HR 0.41, 95%CI 0.25-0.67) and shortest among residents not taking statins or SSRIs (P < 0.001). The survival benefit remained significant after adjusting for age and after conducting a multivariate analysis adjusted for sex, functional status, body mass index, mini-mental state examination, feeding status, arrhythmia, diabetes mellitus, chronic kidney disease, and hemato-oncological diagnosis. CONCLUSIONS: Treatment with statins and/or SSRIs at baseline was associated with longer survival in debilitated nursing home residents and should not be deprived from these patients, if medically indicated.

Clinical presentation, management and outcomes of Staph aureus bacteremia (SAB) in older adults.

AIM: The incidence of Staphylococcus aureus bacteremia (SAB) increases with advancing age with higher mortality reported in older adults. We aimed to describe the clinical presentation, management and outcomes of older patients with SAB. METHODS: We analyzed data from a retrospectively collected database including 1692 patients with SAB, and compared 1158 older patients (≥65 years) with 534 younger patients (<65 years) in terms of clinical features, management of infection, and outcomes. RESULTS: Older patients were significantly less likely to be febrile on presentation, with 37.5 % (415/1106) of older patients presenting with normal body temperature [versus 29.2 % (152/520) of younger patients]. Older patients were however, more likely to have leukocytosis, septic shock, lower heart rate and lower diastolic blood pressure compared with younger patients. Management of older patients included significantly less imaging studies, performance of transesophageal echocardiogram (TEE) and infectious diseases consultation. TEE was performed less in older patients [124/726 (17.1 %) versus 72/285 (25.3 %)]. Mortality was significantly higher in older patients [550/1158 (47.5 %) versus 124/534 (23.2 %)], with predictors for mortality for the entire cohort in multivariate analysis including older age, higher Charlson comorbidity index, female sex, impaired functional capacity, pneumonia or primary bacteremia, and non-performance of TEE. CONCLUSIONS: Mortality rates in older patients with SAB are higher compared with younger patients. Several diagnostic and therapeutic procedures in the management of SAB were less likely to be performed in older patients in our cohort. These may have implications on outcome and should not be dismissed on the basis of age alone.

Beta-lactam versus beta-lactam-aminoglycoside combination therapy in cancer patients with neutropenia.

BACKGROUND: Continued controversy surrounds the optimal empirical treatment for febrile neutropenia. New broad-spectrum beta-lactams have been introduced as single treatment, and classically, a combination of a beta-lactam with an aminoglycoside has been used. OBJECTIVES: To compare beta-lactam monotherapy versus beta-lactam-aminoglycoside combination therapy for cancer patients with fever and neutropenia. SEARCH METHODS: The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 7, 2012), LILACS (August 2012), MEDLINE and EMBASE (August 2012) and the Database of Abstracts of Reviews of Effects (DARE) (Issue 3, 2012). We scanned references of all included studies and pertinent reviews and contacted the first author of each included trial, as well as the pharmaceutical companies. SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing any beta-lactam antibiotic monotherapy with any combination of a beta-lactam and an aminoglycoside antibiotic, for the initial empirical treatment of febrile neutropenic cancer patients. All cause mortality was the primary outcome assessed. DATA COLLECTION AND ANALYSIS: Data concerning all cause mortality, infection related mortality, treatment failure (including treatment modifications), super-infections, adverse effects and study quality measures were extracted independently by two review authors. Risk ratios (RRs) with their 95% confidence intervals (CIs) were estimated. Outcomes were extracted by intention-to-treat (ITT) analysis whenever possible. Individual domains of risk of bias were examined through sensitivity analyses. Published data were complemented by correspondence with authors. MAIN RESULTS: Seventy-one trials published between 1983 and 2012 were included. All cause mortality was lower with monotherapy (RR 0.87, 95% CI 0.75 to 1.02, without statistical significance). Results were similar for trials comparing the same beta-lactam in both trial arms (11 trials, 1718 episodes; RR 0.74, 95% CI 0.53 to 1.06) and for trials comparing different beta-lactams－usually a broad-spectrum beta-lactam compared with a narrower-spectrum beta-lactam combined with an aminoglycoside (33 trials, 5468 episodes; RR 0.91, 95% CI 0.77 to 1.09). Infection related mortality was significantly lower with monotherapy (RR 0.80, 95% CI 0.64 to 0.99). Treatment failure was significantly more frequent with monotherapy in trials comparing the same beta-lactam (16 trials, 2833 episodes; RR 1.11, 95% CI 1.02 to 1.20), and was significantly more frequent with combination therapy in trials comparing different beta-lactams (55 trials, 7736 episodes; RR 0.92, 95% CI 0.88 to 0.97). Bacterial super-infections occurred with equal frequency, and fungal super-infections were more common with combination therapy. Adverse events were more frequent with combination therapy (numbers needed to harm 4; 95% CI 4 to 5). Specifically, the difference with regard to nephrotoxicity was highly significant. Adequate trial methods were associated with a larger effect estimate for mortality and smaller effect estimates for failure. Nearly all trials were open-label. No correlation was noted between mortality and failure rates and these trials. AUTHORS' CONCLUSIONS: Beta-lactam monotherapy is advantageous compared with beta-lactam-aminoglycoside combination therapy with regard to survival, adverse events and fungal super-infections. Treatment failure should not be regarded as the primary outcome in open-label trials, as it reflects mainly treatment modifications.

Infection-control interventions for cancer patients after chemotherapy: a systematic review and meta-analysis.

To quantify the evidence for infection-control interventions among high-risk cancer patients and haematopoietic stem-cell recipients, we did a systematic review of prospective comparative studies. Protective isolation, including air quality control, prophylactic antibiotics, and barrier isolation (29 studies), brought about a significant reduction in all-cause mortality: risk ratio 0.60 (95% CI 0.50-0.72) at 30 days (number needed to treat [NNT] 20 [95% CI 14-33]) and 0.86 (95% CI 0.81-0.91) at the longest follow-up (up to 3 years; NNT 12 [95% CI 9-20]). Inclusion of prophylactic antibiotics in the intervention was necessary to show the effect on mortality. The combined intervention reduced bacteraemia, and Gram-negative, Gram-positive, and Candida spp infections. Mould infections were not significantly reduced. 11 non-randomised prospective studies assessed inpatient versus outpatient management after autologous stem-cell transplantation. All-cause mortality was lower among outpatients: risk ratio 0.72 [95% CI 0.55-0.95]. We conclude that prophylactic antibiotics are the most effective treatment within the protective environment. Randomised trials on outpatient management of haematological cancer patients are needed.

Risk factors for short- and long-term mortality in very old patients with Clostridium difficile infection: A retrospective study.

AIM: Most cases of Clostridium difficile infections (CDI) occur in patients aged 65 years and older. Older age is associated with increased mortality. Risk factors for mortality in patients aged 80 years and older are not well recognized. METHODS: We analyzed retrospective data including 184 patients aged 80 years and older hospitalized with CDI during 2009-2014. We aimed to delineate risk factors for short- and long-term mortality. RESULTS: The 30-day mortality was 33.2%; 1-year mortality was 64.7%. Median survival was 110 days (interquartile range 24-655 days). All four patients who underwent colectomy died. Risk factors for 30-day mortality in multivariate analysis were diabetes mellitus, low albumin and therapy other than metronidazole monotherapy, the latter probably reflecting higher severity of disease rather than a true predictor of mortality. Risk factors for long-term mortality analyzed in Cox regression were albumin ≤2.5 g/dL (HR 0.58, 95% CI 0.395-0.850), presentation with sepsis (HR 0.597, 95% CI 0.408-0.873), a non-independent activities of daily living baseline status (HR 0.460, 95% CI 0.236--0.897) and Charlson score (HR 0.867, 95% CI 0.801-0.938). None of the traditional severity indices for CDI (such as leukocytosis or creatinine increase) proved to be predictors of mortality over the age of 80 years. CONCLUSIONS: The prognosis of old patients with CDI is dismal. Considering the high mortality, efforts to prevent CDI should be first priority in patients aged 80 years and older. Assessment of albumin levels should be part of the evaluation at presentation and considered when choosing treatment, rather than standard severity indexes for CDI. Geriatr Gerontol Int 2017; 17: 1378-1383.

Does Polypharmacy in Nursing Homes Affect Long-Term Mortality?

OBJECTIVES: To investigate the association between polypharmacy and mortality in nursing home (NH) residents. DESIGN: Prospective observational cohort study. SETTINGS: Six NHs in central Israel. PARTICIPANTS: Mobile with dementia and fully dependent residents (N = 764; n = 558 (73%) fully dependent, n = 206 (27%) mobile residents with dementia requiring institutional care; mean age 82.2 ± 5.9). MEASUREMENTS: Two-year mortality and its association with number of drugs that individual residents were taking at baseline, controlled for multiple confounders. RESULTS: At baseline, 268 residents were taking five or fewer drugs per day, 202 were taking six or seven, and 294 were taking eight or more. In the multivariate analysis, the likelihood of dying within 2 years in the group taking six or seven drugs per day (odds ratio (OR = 0.95, 95% CI = 0.63-1.43) and in those taking eight or more (OR = 1.20, 95% CI = 0.78-1.84) was similar to that of those taking five or fewer. Variables at baseline independently associated with greater mortality were male sex (OR = 1.75, 95% CI = 1.24-2.46), older age (OR = 1.07, 95% CI = 1.04-1.10), higher Charlson Comorbidity Index (OR = 1.17, 95% CI = 1.04-1.30), and taking anticoagulant (OR = 1.78, 95% CI = 1.01-3.13) or antihyperglycemic medication (OR = 1.69, 95% CI = 1.12-2.53). Variables at baseline independently associated with lower mortality were higher body mass index (OR = 0.99, 95% CI = 0.93-0.99) and taking lipid-lowering medication (OR = 0.54, 95% CI = 0.36-0.80) and selective serotonin reuptake inhibitors or serotonin-norepinephrine reuptake inhibitors (OR = 0.52, 95% CI = 0.37-0.75). CONCLUSION: Polypharmacy, defined quantitatively according to number of drugs, was not associated with mortality in these NH residents.

Comparing the adequacy of the MNA-SF, NRS-2002 and MUST nutritional tools in assessing malnutrition in hip fracture operated elderly patients.

BACKGROUND & AIMS: Malnutrition is common in hip fracture elderly patients. There is no gold standard for screening nutritional risk. We compared the adequacy of 3 screening tools, their association to nutritional measurements and their ability to predict outcome. METHODS: The Mini Nutrition Assessment Short Form (MNA-SF), the Malnutrition Universal Screening Tool (MUST) and the Nutrition Risk Screening 2002 (NRS-2002) were prospectively determined. Length of stay (LOS), complications, 6 months readmission and up-to 36 months mortality were recorded. RESULTS: 215 operated patients were included: 154 (71.6%) were women; mean age was 83.5 ± 6.09 years (66-104). According to the MNA-SF, 95 patients were well-nourished, 95 were at risk of malnutrition and 25 were malnourished. Based on the MUST, 171 patients were at a low risk of malnutrition, 31 at a medium risk, 13 at a high risk. According to the NRS-2002, 134 patients were at a low risk of malnutrition, 70 at a medium risk, 11 at a high risk. A significant relationship between the nutritional groups of the 3 scores (p < 0.001) was found. In all screening tools, body mass index, weight loss and food intake prior to admission were found to be related to the patients' nutritional status (p < 0.001). No differences in LOS and complications were found between the patients' nutritional status of each screening tool; only the MNA-SF predicted that well-nourished patients would have less readmissions during a 6 month follow-up (p = 0.024). During a 36 month follow-up, 79 patients died. According to the MNA-SF, mortality was lower in the well-nourished patients vs. the malnourished (p = 0.001) and at risk of malnutrition patients (p = 0.01). A less significant association was found between the NRS-2002 patients' nutritional status and mortality (p = 0.048). The MUST did not reveal this relationship. CONCLUSIONS: All screening tools were adequate in assessing malnutrition parameters in hip fracture operated elderly patients, however, only the MNA-SF could also predict readmissions and mortality.

Presentation of infection in older patients--a prospective study.

BACKGROUND: Traditional wisdom suggests that infections in older patients have atypical presentation, including blunted febrile response. Data are scarce. DESIGN: We analyzed data from a prospectively collected database on presentation of infection in 4,308 patients, and compared the presentation of older patients (≥ 75 years) versus adults (< 75 years). SETTINGS: Single tertiary medical center. PARTICIPANTS: Patients admitted with suspected bacterial infection during 2002-2004 and 2010-2011. MEASUREMENTS: We evaluated clinical presentation on day of admission, including vital signs and laboratory parameters. RESULTS: No difference in fever values as a presenting sign of infection was found between older patients and adults (median fever 38.3°C, interquartile range [IQR] 37.4-39.0°C; and 38.4°C, IQR 37.3-39.0°C, respectively, P = 0.08). Median leukocyte count was significantly higher in older patients (median 11.60, IQR 8.30-15.72 in older patients; 10.84, 7.50-15.00 in adults, P < 0.001). Presentation with septic shock, acute renal failure, and reduced consciousness was significantly more common in older patients. These findings were also consistent in the subgroups of bacteremic patients and patients with microbiologically documented infection. CONCLUSION: Elevated fever and leukocytosis were found to be at least equally common in older patients compared to younger adults as part of the presentation of infection.