Preventing and managing frailty in older people

Joining the dots: A blueprint for preventing and managing frailty in older people | British Geriatrics Society

The population of the UK is ageing, with particularly fast growth in the oldest old age groups – by 2045, the number of people aged 85 and above will have almost doubled. In addition, older people are the largest user group of health and social care services. It is therefore essential that commissioners place older people and their health and social care needs at the centre of strategic planning and commissioning processes.

This publication is aimed primarily at system leaders and commissioners of health and social care services for older people, and sets out considerations for planning and commissioning health and social care for older people, alongside actions for systems to create the conditions for high-quality integrated care.

Full document: Joining the dots: A blueprint for preventing and managing frailty in older people

Summary document: Joining the dots: A blueprint for preventing and managing frailty in older people

Association between frailty, chronic conditions and socioeconomic status in community-dwelling older adults attending primary care

Mangin D, Lawson J, Risdon C, et al. | Association between frailty, chronic conditions and socioeconomic status in community-dwelling older adults attending primary care: a cross-sectional study using practice-based research network data | BMJ Open 2023;13:e066269. doi: 10.1136/bmjopen-2022-066269

Frailty is a multidimensional syndrome of loss of reserves in energy, physical ability, cognition and general health. Primary care is key in preventing and managing frailty, mindful of the social dimensions that contribute to its risk, prognosis and appropriate patient support. This paper studied associations between frailty levels and both chronic conditions and socioeconomic status.

The study demonstrates the triple disadvantage of frailty, disease burden and socioeconomic disadvantage. Frailty care needs a health equity approach: the authors demonstrate the utility and feasibility of collecting patient-level data within primary care. Such data can relate social risk factors, frailty and chronic disease towards flagging patients with the greatest need and creating targeted interventions.

Full paper: Association between frailty, chronic conditions and socioeconomic status in community-dwelling older adults attending primary care: a cross-sectional study using practice-based research network data

Supporting older people with health problems to stay well at home

via Age UK

This report provides a first-hand account of older people’s difficulties in getting the good, joined up health and social care they need to manage at home, leaving them at risk of crisis which often results in being admitted to hospital. Yet the evidence is clear that with the right care at the right time many of these admissions could have been avoided.

The report includes perspectives from professionals and unpaid carers. It also shows how living with multiple long term health conditions, as a significant proportion of older people do, including more than two thirds of those aged over 85, makes it especially hard to navigate health services which are still usually organised around individual illnesses and diseases.

Full report: Fixing the foundations. Why it’s time to rethink how we support older people with health problems to stay well at home

Press release: “The crisis in the NHS is largely a crisis in older people’s preventive care, and if we’re to avoid another catastrophic winter in nine months’ time we need to act now to fix it” warns Age UK

Adverse drug reactions in older adults

Adverse drug reactions and associated patient characteristics in older community-dwelling adults: a 6-year prospective cohort study | British Journal of General Practice 23 January 2023 | DOI: https://doi.org/10.3399/BJGP.2022.0181

Approximately 1 in 4 older adults attending general practice experienced an adverse drug reaction (ADR), according to a recent study conducted over a 6-year period. Female sex and taking 10 or more medicines resulted in increased likelihood of an ADR. Although most ADRs were mild, a considerable proportion of moderate ADRs resulted in additional healthcare use. It’s important for older people and their primary care prescribers to consider ADRs when a patient presents with a new symptom.

Full research paper: Adverse drug reactions and associated patient characteristics in older community-dwelling adults: a 6-year prospective cohort study

Factors affecting the decision to investigate older adults with potential cancer symptoms

British Journal of General Practice 2022; 72 (714): e1-e10.| DOI: https://doi.org/10.3399/BJGP.2021.0257

Older age and frailty increase the risk of morbidity and mortality from cancer surgery and intolerance of chemotherapy and radiotherapy. The effect of old age on diagnostic intervals is unknown; however, older adults need a balanced approach to the diagnosis and management of cancer symptoms, considering the benefits of early diagnosis, patient preferences, and the likely prognosis of a cancer.

The aim of this systematic review was to examine the association between older age and diagnostic processes for cancer, and the specific factors that affect diagnosis.

Thematic synthesis highlighted three important factors that resulted in uncertainty in decisions involving older adults: presence of frailty, comorbidities, and cognitive impairment. Data suggested patients wished to be involved in decision making, but the presence of cognitive impairment and the need for additional time within a consultation were significant barriers.

This review has highlighted uncertainty in the management of older adults with cancer symptoms. Patients and their family wished to be involved in these decisions. Given the uncertainty regarding optimum management of this group of patients, a shared decision-making approach is important.

Full paper: Factors affecting the decision to investigate older adults with potential cancer symptoms: a systematic review

Effect of Vitamin D Supplementation, Omega-3 Fatty Acid Supplementation, or a Strength-Training Exercise Program on Clinical Outcomes in Older Adults: The DO-HEALTH Randomized Clinical Trial

Question  Do vitamin D, omega-3, and a strength-training exercise program alone or in combination prevent 6 health outcomes among relatively healthy adults aged 70 years or older?

Findings  In this randomized trial that included 2157 adults aged 70 years or older, 3-year treatment with vitamin D₃ (2000 IU/d), with omega-3 fatty acids (1 g/d), or with a strength-training exercise program did not result in statistically significant differences in improvement in systolic or diastolic blood pressure, nonvertebral fractures, physical performance, infection rate, or cognition.

Meaning  These findings do not support the use of vitamin D, omega-3, or a strength-training exercise program for these clinical outcomes among relatively healthy older adults.

Reference: JAMA. 2020;324(18):1855-1868.

Elevated LDL cholesterol and increased risk of myocardial infarction and atherosclerotic cardiovascular disease in individuals aged 70–100 years

Background

Findings of historical studies suggest that elevated LDL cholesterol is not associated with increased risk of myocardial infarction and atherosclerotic cardiovascular disease in patients older than 70 years. We aimed to test this hypothesis in a contemporary population of individuals aged 70–100 years.

Methods

We included in our analysis individuals (aged 20–100 years) from the Copenhagen General Population Study (CGPS) who did not have atherosclerotic cardiovascular disease or diabetes at baseline and who were not taking statins. Standard hospital assays were used to measure LDL cholesterol. We calculated hazard ratios (HRs) and absolute event rates for myocardial infarction and atherosclerotic cardiovascular disease, and we estimated the number needed to treat (NNT) in 5 years to prevent one event.

Findings

Between Nov 25, 2003, and Feb 17, 2015, 91 131 individuals were enrolled in CGPS. During mean 7·7 (SD 3·2) years of follow-up (to Dec 7, 2018), 1515 individuals had a first myocardial infarction and 3389 had atherosclerotic cardiovascular disease. Risk of myocardial infarction per 1·0 mmol/L increase in LDL cholesterol was augmented for the overall population (HR 1·34, 95% CI 1·27–1·41) and was amplified for all age groups, particularly those aged 70–100 years. Risk of atherosclerotic cardiovascular disease was also raised per 1·0 mmol/L increase in LDL cholesterol overall (HR 1·16, 95% CI 1·12–1·21) and in all age groups, particularly those aged 70–100 years. Risk of myocardial infarction was also increased with a 5·0 mmol/L or higher LDL cholesterol (ie, possible familial hypercholesterolaemia) versus less than 3·0 mmol/L in individuals aged 80–100 years (HR 2·99, 95% CI 1·71–5·23) and in those aged 70–79 years (1·82, 1·20–2·77). Myocardial infarction and atherosclerotic cardiovascular disease events per 1000 person-years for every 1·0 mmol/L increase in LDL cholesterol were highest in individuals aged 70–100 years, with number of events lower with younger age. The NNT in 5 years to prevent one myocardial infarction or atherosclerotic cardiovascular disease event if all people were given a moderate-intensity statin was lowest for individuals aged 70–100 years, with the NNT increasing with younger age.

Interpretation

In a contemporary primary prevention cohort, people aged 70–100 years with elevated LDL cholesterol had the highest absolute risk of myocardial infarction and atherosclerotic cardiovascular disease and the lowest estimated NNT in 5 years to prevent one event. Our data are important for preventive strategies aimed at reducing the burden of myocardial infarction and atherosclerotic cardiovascular disease in the growing population aged 70–100 years.

Funding

None.

Reference: The Lancet, VOLUME 396, ISSUE 10263, P1644-1652, NOVEMBER 21, 2020

Efficacy and safety of lowering LDL cholesterol in older patients

Background

The clinical benefit of LDL cholesterol lowering treatment in older patients remains debated. We aimed to summarise the evidence of LDL cholesterol lowering therapies in older patients.

Methods

In this systematic review and meta-analysis, we searched MEDLINE and Embase for articles published between March 1, 2015, and Aug 14, 2020, without any language restrictions. We included randomised controlled trials of cardiovascular outcomes of an LDL cholesterol-lowering drug recommended by the 2018 American College of Cardiology and American Heart Association guidelines, with a median follow-up of at least 2 years and data on older patients (aged ≥75 years). We excluded trials that exclusively enrolled participants with heart failure or on dialysis because guidelines do not recommend lipid-lowering therapy in such patients who do not have another indication. We extracted data for older patients using a standardised data form for aggregated study-level data. We meta-analysed the risk ratio (RR) for major vascular events (a composite of cardiovascular death, myocardial infarction or other acute coronary syndrome, stroke, or coronary revascularisation) per 1 mmol/L reduction in LDL cholesterol.

Findings

Data from six articles were included in the systematic review and meta-analysis, which included 24 trials from the Cholesterol Treatment Trialists’ Collaboration meta-analysis plus five individual trials. Among 244 090 patients from 29 trials, 21 492 (8·8%) were aged at least 75 years, of whom 11 750 (54·7%) were from statin trials, 6209 (28·9%) from ezetimibe trials, and 3533 (16·4%) from PCSK9 inhibitor trials. Median follow-up ranged from 2·2 years to 6·0 years. LDL cholesterol lowering significantly reduced the risk of major vascular events (n=3519) in older patients by 26% per 1 mmol/L reduction in LDL cholesterol (RR 0·74 [95% CI 0·61–0·89]; p=0·0019), with no statistically significant difference with the risk reduction in patients younger than 75 years (0·85 [0·78–0·92]; p _interaction=0·37). Among older patients, RRs were not statistically different for statin (0·82 [0·73–0·91]) and non-statin treatment (0·67 [0·47–0·95]; p _interaction=0·64). The benefit of LDL cholesterol lowering in older patients was observed for each component of the composite, including cardiovascular death (0·85 [0·74–0·98]), myocardial infarction (0·80 [0·71–0·90]), stroke (0·73 [0·61–0·87]), and coronary revascularisation (0·80 [0·66–0·96]).

Interpretation

In patients aged 75 years and older, lipid lowering was as effective in reducing cardiovascular events as it was in patients younger than 75 years. These results should strengthen guideline recommendations for the use of lipid-lowering therapies, including non-statin treatment, in older patients.

Funding

None.

Reference: TheLancet, VOLUME 396, ISSUE 10263, P1637-1643, NOVEMBER 21, 2020

Effect of exercise training for five years on all cause mortality in older adults—the Generation 100 study: randomised controlled trial

Objective To evaluate the effect of five years of supervised exercise training compared with recommendations for physical activity on mortality in older adults (70-77 years).

Design Randomised controlled trial.

Setting General population of older adults in Trondheim, Norway.

Participants 1567 of 6966 individuals born between 1936 and 1942.

Intervention Participants were randomised to two sessions weekly of high intensity interval training at about 90% of peak heart rate (HIIT, n=400), moderate intensity continuous training at about 70% of peak heart rate (MICT, n=387), or to follow the national guidelines for physical activity (n=780; control group); all for five years.

Main outcome measure All cause mortality. An exploratory hypothesis was that HIIT lowers mortality more than MICT.

Results Mean age of the 1567 participants (790 women) was 72.8 (SD 2.1) years. Overall, 87.5% of participants reported to have overall good health, with 80% reporting medium or high physical activity levels at baseline. All cause mortality did not differ between the control group and combined MICT and HIIT group. When MICT and HIIT were analysed separately, with the control group as reference (observed mortality of 4.7%), an absolute risk reduction of 1.7 percentage points was observed after HIIT (hazard ratio 0.63, 95% confidence interval 0.33 to 1.20) and an absolute increased risk of 1.2 percentage points after MICT (1.24, 0.73 to 2.10). When HIIT was compared with MICT as reference group an absolute risk reduction of 2.9 percentage points was observed (0.51, 0.25 to 1.02) for all cause mortality. Control participants chose to perform more of their physical activity as HIIT than the physical activity undertaken by participants in the MICT group. This meant that the controls achieved an exercise dose at an intensity between the MICT and HIIT groups.

Conclusion This study suggests that combined MICT and HIIT has no effect on all cause mortality compared with recommended physical activity levels. However, we observed a lower all cause mortality trend after HIIT compared with controls and MICT.

Trial registration ClinicalTrials.gov NCT01666340.

Reference: BMJ 2020;371:m3485

Use of an electronic decision support tool to reduce polypharmacy in elderly people with chronic diseases: cluster randomised controlled trial

Objective To evaluate the effects of a computerised decision support tool for comprehensive drug review in elderly people with polypharmacy.

Design Pragmatic, multicentre, cluster randomised controlled trial.

Setting 359 general practices in Austria, Germany, Italy, and the United Kingdom.

Participants 3904 adults aged 75 years and older using eight or more drugs on a regular basis, recruited by their general practitioner.

Intervention A newly developed electronic decision support tool comprising a comprehensive drug review to support general practitioners in deprescribing potentially inappropriate and non-evidence based drugs. Doctors were randomly allocated to either the electronic decision support tool or to provide treatment as usual.

Main outcome measures The primary outcome was the composite of unplanned hospital admission or death by 24 months. The key secondary outcome was reduction in the number of drugs.

Results 3904 adults were enrolled between January and October 2015. 181 practices and 1953 participants were assigned to electronic decision support (intervention group) and 178 practices and 1951 participants to treatment as usual (control group). The primary outcome (composite of unplanned hospital admission or death by 24 months) occurred in 871 (44.6%) participants in the intervention group and 944 (48.4%) in the control group. In an intention-to-treat analysis the odds ratio of the composite outcome was 0.88 (95% confidence interval 0.73 to 1.07; P=0.19, 997 of 1953 v 1055 of 1951). In an analysis restricted to participants attending practice according to protocol, a difference was found favouring the intervention (odds ratio 0.82, 95% confidence interval 0.68 to 0.98; 774 of 1682 v 873 of 1712, P=0.03). By 24 months the number of prescribed drugs had decreased in the intervention group compared with control group (uncontrolled mean change −0.42 v 0.06: adjusted mean difference −0.45, 95% confidence interval −0.63 to −0.26; P<0.001).

Conclusions In intention-to-treat analysis, a computerised decision support tool for comprehensive drug review of elderly people with polypharmacy showed no conclusive effects on the composite of unplanned hospital admission or death by 24 months. Nonetheless, a reduction in drugs was achieved without detriment to patient outcomes.

Trial registration Current Controlled Trials ISRCTN10137559.

Reference: BMJ 2020;369:m1822