Comparison of different frailty instruments for prediction of functional decline in older hypertensive outpatients (HYPER-FRAIL pilot study 2).

BACKGROUND AND AIMS: Few studies have evaluated frailty in older hypertensive individuals and the most appropriate tools to identify frailty in this population have yet to be identified. This study compared the performance of six frailty instruments in the prediction of 1-year functional decline in older hypertensive outpatients. METHODS: The HYPERtension and FRAILty in Older Adults (HYPER-FRAIL) longitudinal pilot study involved hypertensive participants ≥75 years from two geriatric outpatient clinics at Careggi Hospital, Florence, Italy, undergoing identification of frailty with four frailty scales (Fried Frailty Phenotype, Frailty Index [FI], Clinical Frailty Scale [CFS], Frailty Postal Score) and two physical performance tests (Short Physical Performance Battery [SPPB] and gait speed). Prediction of 1-year functional decline (i.e. a ≥ 10-point Barthel Index decrease between baseline and follow-up) was examined based on ROC curve analysis and multivariable logistic regression. RESULTS: Among 116 participants, 24 % reported functional decline. In the ROC curve analyses, FI (AUC=0.76), CFS (AUC=0.77), gait speed (AUC=0.73) and the SPPB (AUC=0.77) achieved the best predictive performance, with FI ≥0.21 and CFS ≥4 showing the highest sensitivity (82 %) and negative predictive value (91 %). Frailty identified with FI, CFS or physical performance tests was associated with an increased risk of 1-year functional decline, independently of baseline functional status and comorbidity burden. CONCLUSIONS: FI, CFS and physical performance tests showed similar predictive ability for functional decline in hypertensive outpatients. The CFS and gait speed might be more suitable for clinical use and may be useful to identify non-frail individuals at lower risk of functional decline.

Tolerability of Antihypertensive Medications: The Influence of Age.

INTRODUCTION: Despite high prevalence of hypertension, few studies have analysed the adverse effects (AEs) of antihypertensive medications, especially in older patients. AIM: To investigate the prevalence and associated factors of antihypertensive-related AEs, focusing on the influence of age on treatment tolerability. METHODS: We retrospectively investigated antihypertensive-related AEs in patients evaluated at the Hypertension Clinic of Careggi Hospital, Florence, Italy, between January 2017 and July 2020. Multivariable regression models were generated to analyse variables associated with AEs in the overall sample and in participants ≥75 years. RESULTS: Among 622 subjects (mean age 64.8 years, 51.4% female), the most frequently reported AEs were calcium-channel blockers (CCB)-related ankle swelling (26.8%) and ACEi-induced cough (15.1%). Ankle swelling was more common in older patients (35.7% vs 22.3%, p = 0.001; odds ratio [OR] 1.94, 95%CI 1.289-2.912) and was independently associated with Body Mass Index (BMI, adjOR 1.073) and angiotensin-receptor antagonists (adjOR 1.864). The association with BMI was confirmed in older patients (adjOR 1.134). ACEi-induced cough showed similar prevalence in younger and older patients (13.9% vs 15.6%, p = 0.634), being independently associated with female sex (adjOR 2.118), gastroesophageal reflux disease (GERD, adjOR 2.488) and SNRI therapy (adjOR 8.114). The association with GERD was confirmed in older patients (adjOR 3.238). CONCLUSIONS: CCB-related ankle swelling and ACEi-induced cough represent the most common antihypertensive-related AEs, also at old age. Older patients showed a two-fold increased risk of ankle swelling, that was also independently associated with BMI. ACEi-induced cough had similar prevalence at younger and old ages, being independently associated with GERD.

Prevalence and correlates of frailty in older hypertensive outpatients according to different tools: the HYPER-FRAIL pilot study.

OBJECTIVES: To date, few studies have investigated frailty in hypertensive individuals. This study aimed at identifying the prevalence of frailty in a sample of hypertensive older outpatients using six different identification tools. Clinical correlates of frailty and agreement between different frailty definitions were also investigated. METHODS: The HYPER-FRAIL pilot study recruited hypertensive patients aged at least 75 years from two geriatric outpatient clinics of Careggi Hospital, Florence, Italy. Four frailty scales [Fried Frailty Phenotype, Frailty Index, Clinical Frailty Scale (CFS), Frailty Postal Score] and two physical performance tests [Short Physical Performance Battery (SPPB) and usual gait speed] were applied. The Cohen's kappa coefficient was calculated to assess agreement between measures. Multiple logistic regression was used to identify clinical features independently associated with frailty. RESULTS: Among 121 participants (mean age 81, 60% women), frailty prevalence varied between 33 and 50% according to the tool used. Moderate agreement was observed between Fried Frailty Phenotype, Frailty Index and SPPB, and between Frailty Index and CFS. Agreement was minimal or weak between the remaining measures (K < 0.60). Use of walking aids and depressive symptoms were independently associated with frailty, regardless of the definition used. Frailty correlates also included dementia, disability and comorbidity burden, but not office and 24-h blood pressure values. CONCLUSION: Frailty is highly prevalent among older hypertensive outpatients, but agreement between different frailty tools was moderate-to-weak. Longitudinal studies are needed to assess the prognostic role of different frailty tools and their clinical utility in the choice of antihypertensive treatment.

Impact of SARS-CoV2 infection on mortality and hospitalization in nursing home residents during the "Omicron era".

BACKGROUND: Widespread vaccination and emergence of less aggressive SARS-CoV2 variants may have blunted the unfavourable outcomes of COVID-19 in nursing home (NH) residents. We analysed the course of COVID-19 epidemic in NHs of Florence, Italy, during the "Omicron era" and investigated the independent effect of SARS-CoV2 infection on death and hospitalization risk. METHODS: Weekly SARS-CoV2 infection rates between November 2021 and March 2022 were calculated. Detailed clinical data were collected in a sample of NHs. RESULTS: Among 2044 residents, 667 SARS-CoV2 cases were confirmed. SARS-CoV2 incidence sharply increased during the Omicron era. Mortality rates did not differ between SARS-CoV2-positive (6.9%) and SARS-CoV2-negative residents (7.3%, p = 0.71). Chronic obstructive pulmonary disease and poor functional status, but not SARS-CoV2 infection independently predicted death and hospitalization. CONCLUSIONS: Despite that SARS-CoV2 incidence increased during the Omicron era, SARS-CoV2 infection was not a significant predictor of hospitalization and death in the NH setting.

Screening for cognitive impairment in older adults with hypertension: the HYPER-COG study.

Hypertension is a major risk factor for dementia. Yet, the most suitable cognitive screening test for hypertensive patients has yet to be identified. This study investigated cognitive impairment in hypertensive older adults and compared the discriminative ability of the most widely used cognitive screening tests. The study involved hypertensive patients aged 65+ without prior diagnosis of cognitive impairment, from the Hypertension Clinic of Careggi Hospital, Florence, Italy. Mini Mental State Examination (MMSE), Montreal Cognitive Assessment (MoCA), MiniCog and Clock Drawing Test (CDT) were administered, using a comprehensive neuropsychological assessment as gold standard. The ROC curve analysis and the paired chi-square test were used to compare the discriminative ability, sensitivity and specificity for cognitive impairment of the different screening instruments. Cognitive impairment was diagnosed in 37% of 94 participants (mean age 76, 55% female), mainly involving attention and executive functions. The MoCA (AUC = 0.746), the MMSE (AUC = 0.689) and the MiniCog (AUC = 0.684) showed similar ability in detecting cognitive impairment, while the CDT had a poorer discriminative capacity (AUC = 0.535). The sensitivity of MoCA (80%) and of MMSE/MiniCog combination (74%) was higher in comparison with MiniCog alone (49%, p = 0.007 and 0.004, respectively), while MiniCog achieved the highest specificity (88%, p < 0.001 vs all). Cognitive impairment was detected in more than one-third of hypertensive older adults without prior diagnosis of dementia. MoCA, MMSE and MiniCog showed similar discriminative ability for cognitive impairment, with MoCa and MMSE showing greater sensitivity and MiniCog the highest specificity.

Accuracy of home blood pressure measurement: the ACCURAPRESS study - a proposal of Young Investigator Group of the Italian Hypertension Society (Società Italiana dell'Ipertensione Arteriosa).

PURPOSE: Home blood pressure monitoring (HBPM) might be considered a valid alternative to ambulatory blood pressure monitoring (ABPM) for both the diagnosis and management of hypertension. Correct information on how to perform HBPM are crucial for its reliability. The aim of the present survey was to assess if hypertensive patients followed current recommendation on how to correctly perform HBPM measurements. MATERIALS AND METHODS: The survey included 30 different items on how to perform the HBPM. It was developed by the 'Young Investigators' group of the Italian Society of Arterial Hypertension (SIIA) and it was administered during the office visit between May 2019 and December 2021. RESULTS: A total of 643 hypertensive patients participated in the study. Main results show that, despite the rate of informed patients was relatively high (71% of the whole population), unacceptable number of patients did not follow indications on how to perform a correct HBPM. Patients who were informed on how to measure home BP had a significantly higher rate of correct position during measurement (78 vs. 22%, p < 0.01), avoidance of talking and moving during measurement (68 vs. 32%, p < 0.0001), and correct number and time interval between two measurements (85 vs. 15%, p < 0.001). More accurate measurements of home BP were associated with less prevalence of carotid plaque. CONCLUSIONS: Correct performance for HBPM is low among patients treated in Italian hypertension centers. These findings shed light on the importance of correct HBPM measurements for the detection of accurate BP values for the proper management of hypertensive patients.

The Effects of Pain and Analgesic Medications on Blood Pressure.

PURPOSE OF REVIEW: To review the blood pressure (BP) effects of pain and analgesic medications and to help interpret BP changes in people suffering from acute or chronic pain. RECENT FINDINGS: Acute pain evokes a stress response which prompts a transient BP increase. Chronic pain is associated with impaired regulation of cardiovascular and analgesia systems, which may predispose to persistent BP elevation. Also analgesics may have BP effects, which vary according to the drug class considered. Data on paracetamol are controversial, while multiple studies indicate that non-steroidal anti-inflammatory drugs may increase BP, with celecoxib showing a lesser impact. Hypotension has been reported with opioid drugs. Among adjuvants, tricyclic antidepressants and serotonin-norepinephrine reuptake inhibitors could be pro-hypertensive due to potentiation of adrenergic transmission. Pain and analgesics may induce a clinically significant BP destabilization. The implications on hypertension incidence and BP control remain unclear and should be explored in future studies.

Cardiac Rehabilitation in Advanced aGE after PCI for acute coronary syndromes: predictors of exercise capacity improvement in the CR-AGE ACS study.

BACKGROUND: The positive effect of cardiac rehabilitation (CR) on outcomes after acute coronary syndromes (ACS) is established. Nevertheless, enrollment rates into CR programs remain low, although ACS carry a high risk of functional decline particularly in the elderly. AIM: We aimed to determine if a multidisciplinary CR improves exercise capacity in an older population discharged after ACS systematically treated with PCI. METHODS: CR-AGE ACS is a prospective, single-center, cohort study. All patients aged 75+ years consecutively referred to Cardiac Rehabilitation outpatient Unit at Careggi University Hospital, were screened for eligibility. Moderate/severe cognitive impairment, disability in 2+ basic activities of daily living, musculoskeletal diseases, contraindication to Cardiopulmonary Exercise Test, and diseases with an expected survival < 6 months, were exclusion criteria. Participants attended a CR program, based on 5-day-per-week aerobic training sessions for 4 weeks. RESULTS: We enrolled 253 post-ACS patients with a mean age 80.6 ± 4.4 years. After CR, 136 (56.2%) 77 (31.3%) patients obtained, respectively, at least a moderate (∆+5%) or an optimal (∆+15%) increase in VO2peak. Baseline VO2peak (- 1 ml/kg/min: OR 1.18; 95% CI 1.09-1.28), the number of training sessions (+1 session: OR 1.07; 95% CI 1.01-1.15), and mild-to-moderate baseline disability (yes vs. no: OR 0.22; 95% CI 0.01-0.57) were the predictors of VO2peak changes. CONCLUSIONS: A CR program started early after discharge from ACS produces a significant increase in exercise capacity in very old patients with mild-to-moderate post-acute physical impairment. Baseline VO2peak, the number of training sessions, and the level of baseline disability are the independent predictors of improvement.

Hypertension management in frail older adults: a gap in evidence.

Hypertension management is challenging in frail older adults. The balance between treatment risks and benefits may be difficult to achieve due to an increased vulnerability to treatment-related adverse events, and limited evidence is available to support clinical decisions. The effects of frailty on blood pressure are unclear, as well as its impact on antihypertensive treatment benefits. Appropriate blood pressure targets in frail patients are debated and the frailty measure which best inform clinical decisions in hypertensive patients has yet to be identified. Therefore, hypertension management in frail older adults still represents a 'gap in evidence'. Knowledge of currently available literature is a fundamental prerequisite to develop future research and may help to implement frailty assessment and improve hypertension management in this vulnerable population. Given these premises, we present a narrative review illustrating the most relevant issues that are a matter of debate and that should be addressed in future studies.

Blood pressure and long-term mortality in older patients: results of the Fiesole Misurata Follow-up Study.

BACKGROUND: Optimal blood pressure (BP) control can prevent major adverse health events, but target values are still controversial, especially in older patients with comorbidities, frailty and disability. AIMS: To evaluate mortality according to BP values in a cohort of older adults enrolled in the Fiesole Misurata Study, after a 6-year follow-up. METHODS: Living status as of December 31, 2016 was obtained in 385 subjects participating in the Fiesole Misurata Study. Patients' characteristics were analysed to detect predictors of mortality. At baseline, all participants had undergone office BP measurement and a comprehensive geriatric assessment. RESULTS: After a 6-year follow-up, 97 participants had died (25.2%). After adjustment for comorbidities and comprehensive geriatric assessment, mortality was significantly lower for SBP 140-159 mmHg as compared with 120-139 mmHg (HR 0.54, 95% CI 0.33-0.89). This result was also confirmed in patients aged 75 + (HR 0.49, 95% CI 0.29-0.85), and in those with disability (HR 0.36, 95% CI 0.15-0.86) or taking antihypertensive medications (HR 0.49, 95% CI 0.28-0.86). DISCUSSION: An intensive BP control may lead to greater harm than benefit in older adults. Indeed, the European guidelines recommend caution in BP lowering in older patients, especially if functionally compromised, to minimize the risk of hypotension-related adverse events. CONCLUSIONS: After a 6-year follow-up, mortality risk was lower in participants with SBP 140-159 mmHg as compared with SBP 120-139 mmHg, in the overall population and in the subgroups of subjects aged 75 + , with a disability or taking anti-hypertensive medications.