Gender differences in the impact of metabolic syndrome components on mortality in older people: A systematic review and meta-analysis.

BACKGROUND AND AIMS: The influence of metabolic syndrome (MetS) on mortality may be influenced by age- and gender-related changes affecting the impact of individual MetS components. We investigated gender differences in the association between MetS components and mortality in community-dwelling older adults. METHODS AND RESULTS: Prospective studies were identified through a systematic literature review up to June 2019. Random-effect meta-analyses were run to estimate the pooled relative risk (RR) and 95% confidence intervals (95% CI) of all-cause and cardiovascular (CV) mortality associated with the presence of MetS components (abdominal obesity, high triglycerides, low HDL cholesterol, high fasting glycemia, and high blood pressure) in older men and women. Meta-analyses considering all-cause (103,859 individuals, 48,830 men, 55,029 women; 10 studies) and CV mortality (94,965 individuals, 44,699 men, 50,266 women; 8 studies) did not reveal any significant association for abdominal obesity and high triglycerides in either gender. Low HDL was associated with increased all-cause (RR = 1.16, 95% CI: 1.02-1.32) and CV mortality (RR = 1.34, 95% CI: 1.03-1.74) among women, while weaker results were found for men. High fasting glycemia was associated with higher all-cause mortality in older women (RR = 1.35, 95% CI: 1.22-1.50) more than in older men (RR = 1.21, 95% CI: 1.13-1.30), and CV mortality only in the former (RR = 1.36, 95% CI: 1.04-1.78). Elevated blood pressure was associated with increased all-cause mortality (RR = 1.16, 95% CI: 1.03-1.32) and showed marginal significant results for CV death only among women. CONCLUSIONS: The impact of MetS components on mortality in older people present some gender differences, with low HDL cholesterol, hyperglycemia, and elevated blood pressure being more strongly associated to all-cause and CV mortality in women.

Decision tree for ward admissions of older patients at the emergency department after a fall.

AIM: Falls are a prevalent issue for the older population, and for the healthcare system in terms of emergency department (ED) access and hospitalizations. There is still a lack of knowledge and guidelines, however, regarding the need to hospitalize older patients accessing the ED after a fall. In the present study, we aimed to analyze the factors and the decisional process that led to older patients accessing the ED after a fall being admitted to hospital or discharged. METHODS: The study sample included 2144 older people who accessed the ED after a fall. For each patient, we obtained information on the nature of the fall and the related injuries, previous falls, dementia and ongoing medical therapies. As the outcome variable, we considered the indication for ward admission after the ED visit. RESULTS: Of the 2144 individuals who accessed the ED after a fall, 38% had at least one fracture, and 40.1% were admitted to a ward. The decision tree obtained using the chi-squared automatic interaction detection algorithm showed that the indication for ward admission could be accurately predicted (risk estimate 0.205) by just five factors, namely: presence and severity of fall-related injuries, reportedly suspicious fall dynamics, use of anticoagulants, polypharmacy, and dementia. CONCLUSIONS: The need for ward admission in older patients who access the ED after a fall seems to be determined not only by the severity of fall-related injuries, but also by the fall dynamics and the individual's clinical complexity. Geriatr Gerontol Int 2018; 18: 1388-1392.

Short- and longer-term predictive capacity of the Multidimensional Prognostic Index: The timing of the assessment is of no consequence.

BACKGROUND: Several studies have tested the ability of the Multidimensional Prognostic Index (MPI) to predict mortality for acute elderly patients admitted to hospital. We compared the reliability of MPI scores obtained both on admission to, and at discharge from hospital. We tested MPI performance in predicting short- and longer-term mortality grouped into three risk groups and according to single MPI scores. METHODS: A longitudinal prospective study was conducted on 699 elderly patients admitted to the Geriatric Unit at Padua General Hospital. MPI scores were obtained on admission and at discharge. In-hospital and one-year mortality was recorded. Adjusted Cox's regression models were used to assess the prognostic value of the MPI scores. RESULTS: 691 were included in the study: 459 (66.4%) women and 232 (33.6%) men, mean age=85.2 ± 7.0 years. Patients were grouped as: low risk MPI 12.5%; moderate risk MPI 28.6%; severe risk MPI 58.9%. The cumulative in-hospital mortality rate was 7.4%. In the adjusted model, only MPI score (not MPI risk group) was significantly associated with in-hospital death ([HR]=1.22, 95%CI 1.07-1.39). 1-Year crude mortality rate: 39.2%. The patients' MPI scores at admission and at discharge were equally predictive of death (adjusted HR of MPI on admission 1.20 [1.15-1.27], p<0.0001; at discharge 1.24 [1.18-1.30], p<0.0001). The performance (AUC) of the MPI score on admission and at discharge proved much the same. CONCLUSIONS: This study confirmed the value of the MPI in predicting mortality for acute elderly patients. Grouping MPI scores into risk levels may not be appropriate when applied to hospitalized acute geriatric patients. The prognostic value of MPI scores was confirmed only for MPI value ≥0.68. Judging from our study, the timing of the assessment during a patient's hospital stay (on admission or at discharge) may be irrelevant for longer-term prognostic purposes.

Does the Multidimensional Prognostic Index (MPI), based on a Comprehensive Geriatric Assessment (CGA), predict mortality in cancer patients? Results of a prospective observational trial.

OBJECTIVE: Despite the lack of definitive data on the impact of Comprehensive Geriatric Assessment (CGA) in the geriatric oncology setting, the broad use of any form of CGA is strongly recommended before any treatment decision in elderly cancer patients (ECP); currently there is no consensus about the best format for this geriatric assessment. The aim of this study was to firstly test the Multidimensional Prognostic Index (MPI) in ECP with locally advanced or metastatic disease. MATERIALS AND METHODS: Patients aged ≥70years with inoperable or metastatic solid cancer consecutively admitted to our Program of Geriatric Oncology were assessed by a multidisciplinary team and received a basal CGA to calculate the MPI score. RESULTS: A hundred and sixty patients entered the study. In the Cox's regression model, MPI, CIRS-SI, BSA, GDS, MMSE, chemotherapy and a diagnosis of primary lung cancer were associated with mortality at 6 and 12months. The ROC curves confirmed the prognostic value of MPI, with the best discriminatory power for mortality at both 6 and 12months. CONCLUSION: The present study is the first to indicate that the MPI retains its prognostic value even in elderly cancer patients with advanced stage of disease. The CIRS-SI and the GDS may potentiate the prognostic value of MPI.

Role of comprehensive geriatric assessment in the management of osteoporotic hip fracture in the elderly: an overview.

PURPOSE: To highlight the advantages of comprehensive geriatric assessment (CGA) over usual care in the management of elderly patients with fragility hip fractures in terms of reducing the related mortality and disability. METHOD: An overview of publications on the topic was conducted using the MEDLINE and EMBASE databases. RESULTS: Several models of geriatric and orthopedic comanagement have been developed in recent years, all characterized by a variable degree of integration, and they have been shown to reduce complications, disability and mortality in elderly hip-fracture patients. Preoperatively, CGA should identify the comorbidities that need to be treated in view of surgery, so as to reduce the related risks. After surgery, CGA should deal with medical complications and assure patients an early mobilization in order to reduce short-term mortality and contain functional decline. Before discharge, the orthogeriatric team should draw up a tailored program to promote the patient's functional recovery and satisfactory quality of life, also covering the secondary prevention of fragility fractures by improving bone quality and reducing the risk of falls. CONCLUSIONS: Fragility hip fractures in the elderly people need to be managed by different professionals working in close cooperation and adopting a CGA.

The potential of classic and specific bioelectrical impedance vector analysis for the assessment of sarcopenia and sarcopenic obesity.

PURPOSE: The aim of this paper is to investigate whether bioelectrical impedance vector analysis (BIVA) can be a suitable technique for the assessment of sarcopenia. We also investigate the potential use of specific BIVA as an indicator of sarcopenic obesity. SUBJECTS AND METHODS: The sample comprised 207 free-living elderly individuals of both sexes, aged 65 to 93 years. Anthropometric and bioelectrical measurements were taken according to standard criteria. The "classic" and "specific" BIVA procedures, which respectively correct bioelectrical values for body height and body geometry, were used. Dual energy X-ray absorptiometry (DXA) was used as the reference method for identifying sarcopenic and obese sarcopenic individuals. Bioelectrical and DXA values were compared using Student's t-test and Hotelling's T(2) test, as well as Pearson's correlation coefficient. RESULTS: According to classic BIVA, sarcopenic individuals of both sexes showed higher values of resistance/height (R/H; p < 0.01) and impedance/height (Z/H; p < 0.01), and a lower phase angle (p < 0.01). Similarly, specific BIVA showed significant differences between sarcopenic and nonsarcopenic individuals (men: T(2) = 15.7, p < 0.01; women: T(2) = 10.7, p < 0.01), with the sarcopenic groups showing a lower specific reactance and phase angle. Phase angle was positively correlated with the skeletal muscle mass index (men: r = 0.52, p < 0.01; women: r = 0.31, p < 0.01). Specific BIVA also recognized bioelectrical differences between sarcopenic and sarcopenic obese men (T(2) = 13.4, p < 0.01), mainly due to the higher values of specific R in sarcopenic obese individuals. CONCLUSION: BIVA detected muscle-mass variations in sarcopenic individuals, and specific BIVA was able to discriminate sarcopenic individuals from sarcopenic obese individuals. These procedures are promising tools for screening for presarcopenia, sarcopenia, and sarcopenic obesity in routine practice.

Polypharmacy in the elderly: can comprehensive geriatric assessment reduce inappropriate medication use?

Polypharmacy is a problem of growing interest in geriatrics with the increase in drug consumption in recent years, particularly among people aged >65 years. The main reasons for polypharmacy are longer life expectancy, co-morbidity and the implementation of evidence-based clinical practice guidelines. However, polypharmacy also has important negative consequences, such as a higher risk of adverse drug reactions and a decline in medication efficacy because of reduced compliance. Comprehensive geriatric assessment (CGA) has proved effective in reducing the number of prescriptions and daily drug doses for patients by facilitating discontinuation of unnecessary or inappropriate medications. CGA has also demonstrated an ability to optimize treatment by increasing the number of drugs taken in cases where under-treatment has been identified. Greater multidimensional and multidisciplinary efforts are nonetheless needed to tackle polypharmacy-related problems in frail elderly patients. CGA should help geriatrics staff identify diseases with higher priority for treatment, thereby achieving better pharmacological treatment overall in elderly patients. The patient's prognosis should also be considered in the treatment prioritization process. The most appropriate medication regimen should combine existing evidence-based clinical practice guidelines with data gathered from CGA, including social and economic considerations. Furthermore, for prescriptions to remain appropriate, the elderly should periodically undergo medication review, particularly as the risk or presence of multiple co-morbidities increases. This article aims to highlight the increasing impact of polypharmacy in the elderly and to underscore the role of CGA in achieving the most appropriate pharmacological treatment in this age group.

Tooth loss in the elderly and its association with nutritional status, socio-economic and lifestyle factors.

OBJECTIVE: Tooth loss impacts on general health and is a risk factor for malnutrition, disability, loss of self-sufficiency, and deterioration in quality of life. The present study was carried out to evaluate the prevalence of edentulism and its association with social and lifestyle factors in a population of elderly Italians. MATERIAL AND METHODS: Dental, social, and disease conditions were evaluated in a large community-based cohort (3054) of elderly subjects (> or =65 years) of both sexes in northern Italy. Logistic regression analyses with stepwise forward selection were performed to estimate the independent contribution of nutritional, socio-economic, and lifestyle variables to dental status. Adjusted ORs and 95% CI were estimated for variables significantly associated with edentulism. RESULTS: The prevalence of edentulism was about 44.0%. It was more pronounced in females and it was twice as prevalent in the 90+ years age group. Among edentulous subjects, 17.5% wore no prostheses. Difficulties in chewing and in swallowing were reported by 47.6% and 13.7% of the subjects, respectively. Multivariate analysis indicates that edentulism was associated with age in both sexes. For women, independently associated risk factors were: years since menopause >23 (OR = 1.81; 95% CI: 1.37-2.40), number of children >3 (OR = 1.95; 95% CI: 1.36-2.80), and living alone (OR = 1.47; 95% CI: 1.15-1.88). For men, these were serum albumin <40 g/l (OR = 1.79; 95% CI: 1.22-2.63), current smoking (OR = 4.01; 95% CI: 2.59-6.20), and former smoking (OR = 3.42; 95% CI: 2.42-4.82). CONCLUSIONS: The prevalence of edentulism among the elderly Italian population studied was at the high end among Western countries, and higher in women than in men. In women, tooth loss correlated with aging, female events (pregnancies, menopausal status), and living alone. In men, aging and smoking are important determinants of edentulism, which is associated with the risk condition of hypoalbuminemia. Difficulty in chewing was associated with dentition type. In our study, the high prevalence of edentulous subjects without prostheses suggests a need for educational and social measures to improve patients' attitudes to dental care and to encourage the use of prostheses among the elderly.

Resting energy expenditure and body composition in bedridden institutionalized elderly women with advanced-stage pressure sores.

BACKGROUND: Our study investigated nutritional status, body composition, and resting energy expenditure (REE) in elderly patients with advanced-stage pressure sores (PS), in addition to researching any hypermetabolic condition and its relationship with PS size. METHODS: The study involved 52 institutionalized bedridden elderly women (aged 83.7 +/- 6.3 years), divided into two groups: 23 with advanced-stage (stage 3 and 4) PS and 29 without PS. Albumin, prealbumin, and retinol-binding protein were measured in all patients, and fat-free mass (FFM) and fat mass (FM) were obtained by dual-energy x-ray absorptiometry (DEXA). REE was measured by indirect calorimetry and predicted with the Harris-Benedict formula. PS area and volume were also measured. RESULTS: The elderly women with and without PS were comparable in age, FFM, and FM. Mean albumin, prealbumin, and retinol-binding protein values were lower in cases with PS. Unadjusted mean REE was significantly higher in patients with PS (1212.3 +/- 236.7 vs 1085.5 +/- 161.3 kcal/d; p <.05), even after adjusting for FFM or expressed per kilogram of body weight (25.8 +/- 6.7 vs 21.1 +/- 4.0 kcal/d/kg; p <.01). Hypermetabolism, i.e., a measured REE > 110% of the predicted REE, was seen in 74% of patients with PS and 38% of controls. The difference between measured and predicted REE (DeltaREE) correlated with PS volume (r = 0.58; p <.01), but not with area. CONCLUSION: Advanced-stage PS in elderly women are associated with a hypermetabolic state that is influenced by the volume of the PS.