Current evidence on the impact of medication optimization or pharmacological interventions on frailty or aspects of frailty: a systematic review of randomized controlled trials.

BACKGROUND: Frailty and adverse drug effects are linked in the fact that polypharmacy is correlated with the severity of frailty; however, a causal relation has not been proven in older people with clinically manifest frailty. METHODS: A literature search was performed in Medline to detect prospective randomized controlled trials (RCTs) testing the effects of pharmacological interventions or medication optimization in older frail adults on comprehensive frailty scores or partial aspects of frailty that were published from January 1998 to October 2019. RESULTS: Twenty-five studies were identified, 4 on comprehensive frailty scores and 21 on aspects of frailty. Two trials on comprehensive frailty scores showed positive results on frailty although the contribution of medication review in a multidimensional approach was unclear. In the studies on aspects related to frailty, ten individual drug interventions showed improvement in physical performance, muscle strength or body composition utilizing alfacalcidol, teriparatide, piroxicam, testosterone, recombinant human chorionic gonadotropin, or capromorelin. There were no studies examining negative effects of drugs on frailty. CONCLUSION: So far, data on a causal relationship between drugs and frailty are inconclusive or related to single-drug interventions on partial aspects of frailty. There is a clear need for RCTs on this topic that should be based on a comprehensive, internationally consistent and thus reproducible concept of frailty assessment.

Optimizing medical care for geriatric patients in Austria: defining a top five list of "Choosing Wisely" recommendations using the Delphi technique.

PURPOSE: Inappropriate use of diagnostic and therapeutic medical procedures is common and potentially harmful for older patients. The Austrian Society of Geriatrics and Gerontology defined a consensus of five recommendations to avoid overuse of medical interventions and to improve care of geriatric patients. METHODS: From an initial pool of 147 reliable recommendations, 20 were chosen by a structured selection process for inclusion in a Delphi process to define a list of five top recommendations for geriatric medicine. 12 experts in the field of geriatric medicine scored the recommendations in two Delphi rounds. RESULTS: The final five recommendations are concerning urinary catheters in elderly patients, percutaneous feeding tubes in patients with advanced dementia, antipsychotics as the first choice to treat behavioral and psychological symptoms of dementia, and screening for breast, colorectal, prostate, or lung cancer, and the use of antimicrobials to treat asymptomatic bacteriuria. CONCLUSIONS: The selected recommendations have the potential to improve medical care for older patients, to reduce side effects caused by unnecessary medical procedures, and to save costs in the health care system.

[Nutrition at the End of Life - Ethical Aspects]. / Ernährung am Lebensende ­ ethische Aspekte.

Nutritional problems at the end of life are of multifactorial origin, they require an interdisciplinary and multiprofessional approach. A basic precondition in deciding a nutritional therapeutic intervention is a valid medical indication. Fundamental ethical principles have to be respected.Another relevant question is if the nutritional therapeutic intervention will serve a meaningful, attainable goal in accordance with the patient's individual preferences and whether the expected benefit outweighs the potential risks. Particularly in older patients with a higher risk of cognitive impairment there is the question of the patient's ability to communicate his/her personal preferences, if he/she is able to give informed consent.Nutritional problems, particularly the refusal to eat can present a burdensome situation for the patient's carers. The potential reasons and causes for these problems have to be evaluated by an interdisciplinary assessment and medical differential diagnosis. This process has to involve the patient, his family and carers, ethical and palliative care counsel should be available.The topic of artificial feeding by means of a percutaneous gastrostomy - its relevance in the end of life situation, particularly in advanced stages of dementia is also addressed.

[Problems of pain measurement and pain therapy in the elderly]. / Problemfelder in der Schmerzmessung und Schmerztherapie im Alter.

Due to complex physical and psychological changes in aging, pain measurement and therapeutic treatment of older and geriatric patients present a special challenge. Nevertheless, even for this category of patients, good treatment results are achievable if age-related particulars and problems are consistently heeded and accounted for. That includes adverse sensory and cognitive effects as much as multimorbidity and the polypharmacy that is frequently related to it. An essential prerequisite for adequate pain therapeutic care in elderly patients is consistent pain measurement. While numerical and verbal scales have also proven their usefulness for patients in advanced age who are not cognitively impaired, instruments must be applied for older people with communicative and/or cognitive restrictions with which the observed behavior of those involved can be surveyed in a multidimensional way.

Soluble transferrin receptor and iron status in elderly patients.

The measurement of soluble transferrin receptor (sTfR) has been proposed as a novel approach to the diagnosis of iron deficiency, especially in anaemia of chronic diseases (ACD). Our aim was to study the utility of sTfR under 'everyday conditions' as seen in a geriatric hospital in the following groups of patients: First, in a pilot group of 99 multimorbid geriatric patients (85 women, 14 men; 82.00 +/- 6.32 years) admitted for rehabilitation after recent surgical treatment of a bone fracture; second, in 677 geriatric patients (506 women, 171 men; 79.17 +/- 11.47 years) with different diagnoses admitted to a department of internal medicine; third, in some remarkable clinical cases in order to illustrate the diagnostic limits of sTfR. In general, both genders showed a remarkable age-dependent decrease in erythropoiesis. In patients with haemoglobin levels below 12.0 mg/dL, this parameter correlated significantly with sTfR. However, this was seen only in women, not in men. Moreover, an age-dependent increase in sTfR was seen in women, while in men it remained almost constant. Based on these findings, we conclude that there is a different, gender-specific aetiology of iron deficiency in the elderly. About 30% of patients of both genders simultaneously had low haemoglobin levels and low sTfR. This was interpreted as 'adaptation' or 'tolerance' to the iron deficiency. This was illustrated by a clinical case of megaloblastic anaemia: Initially low sTfR rose only during the vitamin B12 substitution and normalized after recovery. We conclude that sTfR provides an insight into the 'dynamics' of iron metabolism: A rise in sTfR indicates an 'acute readiness to refill iron stores', while a low (non-stimulated) sTfR level corresponds to the quite frequent adaptation to iron deficiency and/or inhibition of resorption. Finally, extremely high sTfR levels were observed in some cases of malignancy such as in acute leukaemia and in hypernephroma. Thus, increased sTfR levels can be caused by paraneoplastic effects.