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- Treatment Considerations for Severe Osteoporosis in Older Adults
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Abstract: Osteoporosis, a chronic metabolic bone disease, increases the predisposition to fragility fractures and is associated with considerable morbidity, high health care cost as well as mortality. An elevation in the rate of incident fragility fractures will be observed proportional with the increase in the number of older people worldwide. Severe osteoporosis is currently defined as having a bone density determined by dual-energy X-ray absorptiometry that is more than 2.5 standard deviations (SD) below the young adult mean with one or more past fractures due to osteoporosis. Nutrition, physical activity and adequate vitamin D are essential for optimal bone strength throughout life. Hormone (oestrogen/sex steroid) status is also a major determinant of bone health. This review explores mechanisms involved in bone homeostasis, followed by the assessment and management of severe osteoporosis, including an overview of several treatment options in older people that range from anti-resorptive to anabolic therapies.
PubDate: 2025-04-16
- Comparison of Anticholinergic Burden Scales and Their Association with
Cognitive and Functional Impairment in Older Adults: A Cross-Sectional
Study Using the REPOSI Database-
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Abstract: Background The increasing use of anticholinergic medications in older adults with multiple chronic conditions raises significant concerns regarding their cumulative anticholinergic burden, which is linked to several adverse outcomes. This study aimed to compare existing anticholinergic burden scales to identify those most effective at correlating drug-induced anticholinergic load with cognitive and functional impairment. In addition, we proposed a new classification system on the basis of published scales to optimally correlate total anticholinergic burden with observed clinical deficits. Methods This cross-sectional study analyzed data from the REPOSI registry, which collects clinical and therapeutic information on patients aged 65 years and older admitted to internal medicine and geriatric wards across Italy. Anticholinergic exposure was assessed using 20 established anticholinergic burden scales from literature. In addition, seven experimental scales were developed on the basis of published scales and various mathematical functions (maximum, mode, median, and mean) to evaluate potential differences in measuring anticholinergic load. Outcomes included cognitive impairment, assessed using the Short Blessed Test (SBT), and functional independence, measured by the Barthel Index (BI). A zero-inflated negative binomial model was applied to analyze associations between anticholinergic burden and each outcome. Given the variability in drug scoring across published scales, we developed seven experimental scales using different mathematical functions (maximum, mode, median, and mean) to standardize scoring. Three versions included a null-score adjustment to account for drugs omitted in some scales, ensuring a more comprehensive measure of anticholinergic burden. Results Among 7735 patients, higher anticholinergic burden was consistently associated with increased cognitive impairment (SBT) and physical dependency (BI) across all existing and proposed scales. The modified Anticholinergic Risk Scale (mARS) scale showed the strongest associations with cognitive (rate ratio [RR] 1.10, 95% confidence interval [CI] 1.06, 1.13; P < 0.0001) and physical impairment (RR 1.18, 95% CI 1.11, 1.24; P < 0.0001), indicating an 18% higher risk of dependency per unit increase, while the CRIDECO Anticholinergic Load Scale (CALS) scale exhibited the best model fit. Our newly developed scales confirmed these associations, with the median with null score and the mean with null score scale showing the strongest link to cognitive impairment (RR 1.07, 95% CI 1.05, 1.09; P < 0.0001) and the strongest association with physical dependency (RR 1.11, 95% CI 1.08, 1.15; P < 0.0001). Conclusions Scales that identify a greater proportion of patients with at least one anticholinergic drug may provide a more comprehensive assessment of anticholinergic burden in clinical practice. While no single scale demonstrated a definitive advantage across all outcomes, these scales may identify patients at risk. Prioritizing the use of scales with broader coverage could enhance clinical decision-making and optimize management of polypharmacy in older adults and recognize its potential impact on cognitive and functional outcomes.
PubDate: 2025-04-15
- Management of Late-Onset Rheumatoid Arthritis with Treat-to-Target
Strategy-
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Abstract: The incidence of patients with late-onset rheumatoid arthritis (LORA) is increasing. The clinical diagnosis of LORA is essentially the same as that of young-onset rheumatoid arthritis (YORA), but special attention should be paid to the differences in clinical features between LORA and YORA. Undertreatment of LORA can lead to reduced physical function and increased societal burden. The treat-to-target strategy has been successfully applied in patients with rheumatoid arthritis (RA), but evidence supporting this strategy is still insufficient for LORA. A wide range of factors should be considered and evaluated in addition to age and RA-related factors, including comorbidity/organ damage, psycho-neurological factors, socio-economic factors and frailty. Considering the proportion of patients with LORA achieving clinical remission or low disease activity in observational studies, the treat-to-target strategy could be stratified by age. Patients with LORA aged < 75 years are treated according to the treat-to-target algorithm used for all patients with RA, with clinical remission as the main target and low disease activity as the alternative target. In patients with LORA aged ≥ 75 years, the initial main target is set at low disease activity, which can be escalated to clinical remission with appropriate adaptation of treatment if a favourable balance of effectiveness and safety is struck at the time of achieving low disease activity by 6 months of treatment. Evidence of the efficacy/effectiveness and safety of methotrexate, biological disease-modifying antirheumatic drugs, Janus kinase inhibitors and glucocorticoids in patients with LORA is accumulating, but further research is warranted.
PubDate: 2025-04-09
- Efficacy and Safety of Dupilumab in the Treatment of Refractory Atopic
Dermatitis in Older Adults: A Retrospective, Single-Center Study-
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Abstract: Background Atopic dermatitis (AD) is a chronic inflammatory skin condition that can be particularly challenging to manage in older adults. Dupilumab, a monoclonal antibody targeting the interleukin-4 receptor alpha subunit, has shown promise in treating moderate to severe AD. However, its efficacy and safety in older adults with refractory AD have not been extensively studied. Objective The objective of this study is to evaluate the efficacy and safety of dupilumab in treating older adults with refractory atopic dermatitis and to determine its potential as a therapeutic option in this demographic. Methods A retrospective, single-center study was conducted involving 73 older adults (aged ≥ 60 years) with moderate-to-severe AD. The Eczema Area and Severity Index (EASI), Pruritus Numerical Rating Scales (P-NRS), and Dermatology Life Quality Index (DLQI) scores were recorded at baseline and at weeks 6 and 16. Adverse events (AEs) were also monitored. Results Following dupilumab treatment, a significant reduction in EASI, P-NRS, and DLQI scores was observed compared with baseline (p < 0.0001), indicating improved clinical symptoms and quality of life. Adverse events were mostly mild and did not lead to treatment discontinuation. Conclusions Dupilumab demonstrates significant efficacy and a favorable safety profile in managing refractory AD in older adults, suggesting it as a potential effective therapeutic option for this demographic.
PubDate: 2025-04-05
- Predictors and Moderators of Hospitalisation and Mortality in People with
Dementia Using Antipsychotics: Systematic Review-
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Abstract: Background and Objectives Antipsychotics are used to manage behaviours and psychological symptoms of dementia. While antipsychotics have been associated with increased risk of adverse outcomes, factors associated with these outcomes have been understudied. Thus, the aim of this study was to identify factors associated with risk of hospitalisation and mortality in older people living with dementia using antipsychotics. Methods In total, four databases (Embase, Medline, PsycINFO and Web of Science) were searched from 2010 to 30 April 2024 using keywords and Medical Subject Heading (MeSH) terms related to dementia, older adults, antipsychotics and outcomes (hospitalisation or mortality). Studies including older adults (≥ 65 years) with dementia and extractable data on risk measures were eligible. Risk of bias was assessed using the Joanna Briggs Institute’s critical appraisal tools and narrative synthesis of results was performed. Results Of the 4139 studies identified, 24 were included (Total N [patients] = 587,885) with the majority being cohort studies (N = 23). Antipsychotic-related factors associated with mortality risk included the type of antipsychotic (e.g. typical versus atypical, adjusted hazards ratio [aHR] 1.50, 95% confidence interval [CI] 1.10, 2.10), and dose (high versus low, relative increases ranging from 57 to 155%). Patient-related factors included age (aHR 1.05, 95% CI 1.01, 1.08) and concomitant use of medications (e.g. benzodiazepines, aHR 2.19, 95% CI 1.83, 2.63). Antipsychotic-related factors associated with hospitalisation risk included the type of antipsychotic (e.g. atypical verus typical, aHR 1.17, 95% CI 1.08, 1.27) and dose (high versus low, adjusted odds ratio [aOR] 1.19, 95% CI 1.09, 1.31). Patient-related factors included concomitant benzodiazepine use (aHR 1.55, 95% CI 1.29, 1.86), and new use compared with past use (aOR 3.07, 95% CI 2.84, 3.32). Conclusions This review identified several factors associated with risks of hospitalisation and mortality in antipsychotic users with dementia. Clinicians should consider these risk factors when prescribing antipsychotics to people living with dementia.
PubDate: 2025-04-05
- Detection of Potential Prescribing Cascades in Multimorbid Older Patients
Hospitalised with Acute Illness—An Observational Prospective Prevalence
Study-
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Abstract: Background Prescribing cascades occur when a new drug is prescribed to treat an adverse drug event caused by an existing medication, resulting in unnecessary, or potentially hazardous additional drugs. To date, there are no published studies assessing the prevalence of prescribing cascades in older hospitalised adults. Objective To investigate the prevalence of prescribing cascades in hospitalised older adults. Methods We conducted a prospective observational study of adults aged ≥ 65 years with multimorbidity and polypharmacy presenting to hospital with acute unselected medical or surgical illness. Prescribing cascades were identified using two predefined validated explicit cascade lists, i.e. ThinkCascades, and a list derived from a recently published systematic review of prescribing cascades in community-dwelling adults, referred to here as the ‘Doherty list’. Potential prescribing cascades were classified as ‘definite’, ‘probable’, ‘possible’, ‘uncertain’ or ‘indeterminate’ according to pre-specified criteria. Results The study included 385 consecutive patients (55.1% female, mean age 80.2 years, standard deviation 7.3 years). A total of 281 potential prescribing cascades (drug A → drug B) were identified in 152 patients (39.4%). Probable or possible prescribing cascades were identified in 48 patients (12.4%) using the Doherty list and in 44 patients (11.4%) using ThinkCascades. Patients exposed to potential prescribing cascades experienced greater levels of polypharmacy than patients not exposed to prescribing cascades (median interquartile range [IQR] of 12 [9–14] daily drugs versus 9 [IQR 7–11], p < 0.001). Conclusions Potential prescribing cascades were highly prevalent in older hospitalised adults. Practical tools are needed to assist prescribers in prevention, recognition and management of inappropriate prescribing cascades.
PubDate: 2025-04-04
- Benefit–Risk Assessment of Rivaroxaban in Older Patients With
Nonvalvular Atrial Fibrillation or Venous Thromboembolism-
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Abstract: Background Both bleeding and adverse ischemic events increase with age, compounding the benefit–risk balance of anticoagulants in older patients. We present analyses using benefit–risk methods to better understand the age-dependence of the benefit–risk profile of rivaroxaban in patients with nonvalvular atrial fibrillation (NVAF) or venous thromboembolism (VTE). Methods Randomized controlled trial data from the ROCKET-AF (NVAF) and EINSTEIN DVT, EINSTEIN PE, EINSTEIN-Extension, and EINSTEIN CHOICE in (VTE) were used. For ROCKET-AF, benefits and risks were assessed with incidence rates for key thrombotic and bleeding endpoints and a net clinical benefit (NCB) measure. Cumulative incidences (estimated by the Kaplan–Meier method) were estimated at day 185 for EINSTEIN and EINSTEIN Extension and 1 year for EINSTEIN CHOICE. Incidence differences were calculated for the overall population and age subgroups of < 65, 65–75, and> 75 years. Results In ROCKET-AF, rate differences in the composite NCB outcome (vascular death, stroke, myocardial infarction, fatal bleeding, critical organ bleeding, and non-CNS systemic embolism) favored rivaroxaban overall and by age < 65, 65–75, and> 75 years (−84, −25, −61, and −150 cases per 10,000 patient-years, respectively). In the pooled EINSTEIN DVT and EINSTEIN PE studies, cumulative incidence differences for the composite NCB outcome (recurrent VTE and major bleeding) were −103, 3, −105, and −544 per 10,000 patients, respectively. For extended VTE treatment with rivaroxaban versus placebo in EINSTEIN-Extension, NCB results were −536, −492, −556, and −601 per 10,000 patients, respectively. In the EINSTEIN CHOICE analysis, NCB favored rivaroxaban 20 mg versus aspirin (−284, −255, −339, and −338, respectively) and rivaroxaban 10 mg versus aspirin (−339, −328, −485, and −80, respectively). Conclusions This analysis demonstrated a positive benefit–risk profile with rivaroxaban versus trial comparators in older patients with NVAF or VTE, with benefit–risk increasingly favoring rivaroxaban with increasing age. Clinical Trial Registration: http://ClinicalTrials.gov, identifiers: NCT00403767 (ROCKET-AF), NCT00440193 (EINSTEIN DVT), NCT00439777 (EINSTEIN PE), NCT00439725 (EINSTEIN Extension), and NCT02064439 (EINSTEIN CHOICE).
PubDate: 2025-03-31
- Symptoms of Orthostatic Hypotension and Drugs Affecting Autonomic Function
are Associated with the Onset of Frailty in Community-Dwelling Persons
Aged 80 Years and Above: A Prospective Observational Study-
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Abstract: Background Both autonomic dysfunction and frailty are common and complex geriatric syndromes with similar negative health outcomes. Both conditions are characterized by a loss of homeostasis that makes individuals more vulnerable to stressors. Aim The primary aim of this study is to examine the association between drugs that affect autonomic function and frailty onset in community-dwelling octogenarians. The secondary aim is to investigate the relationship between autonomic dysfunction and frailty onset in this population. Methods In total, 372 nonfrail adults aged 80 years and above (mean age 83 ± 3 years) from the BUTTERFLY project were prospectively followed for 2 years (mean follow-up of 22 ± 6 months). The association between autonomic dysfunction (defined as neurogenic orthostatic hypotension and symptoms of orthostatic hypotension), the use of medications affecting autonomic function, and frailty status were examined using binary logistic regression analysis. Results The completely adjusted binary logistic regression model showed that the use of drugs affecting autonomic function was associated with frailty {adjusted odds ratio (aOR) = 1.78 [95% confidence interval (CI) 1.06–3.00], p = 0.030}. Furthermore, symptoms of orthostatic hypotension were related to frailty (aOR = 2.98 [95% CI 1.13–7.88], p = 0.027). Conclusions Our results show that symptoms of orthostatic hypotension and the use of drugs that affect autonomic function are accompanied with respectively 3-fold and 1.8-fold higher odds of frailty onset in persons aged 80 years and over. Therefore, pharmacological treatment that affects autonomic function should be started with caution and timely discontinued in older persons.
PubDate: 2025-03-29
- International Deprescribing Guidelines Did Not Impact Actual Practice in
Deprescribing of Potentially Inappropriate Medications for Nursing Home
Residents: An Interrupted Time Series Analysis-
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Abstract: Background Deprescribing guidelines reduce the use of potentially inappropriate medications (PIMs) in trial settings; however, their real-world impact remains unclear. Therefore, this study assesses deprescribing trends and the impact of guideline publications (STOPPFrail, proton pump inhibitors [PPIs], and antipsychotics) on these trends among nursing home residents with limited life expectancy in Belgium. Methods Deprescribing was assessed using linked healthcare reimbursement data for all residents aged 65 years and older who died between 2014 and 2019. In total, 15 PIMs from STOPPFrail version 1 were selected. Deprescribing was operationalized as discontinuing at least one PIM in the last 4 months of life among those who had been prescribed these medications chronically between 6–12 months prior to death. To identify changes in the trend of deprescribing, we employed a joinpoint linear regression model. We calculated the average quarterly percent change (AQPC) and 95% confidence intervals (CIs). In addition, we used autoregressive integrated moving average (ARIMA) modeling to explore the impact of publication of these guidelines on four commonly used PIMs: PPIs, antipsychotics, lipid modifying agents, and calcium. Results Among 244,865 residents, 169,782 (69.3%) were chronically prescribed at least one PIM and 50,487 (29.7%) had at least one discontinued. The prevalence of deprescribing declined from 31.7 to 27.66% between the first quarter of 2014 and the fourth quarter of 2019, with an average quarterly percent change decline of − 0.47% (95% CI − 0.85, − 0.10). No joinpoints were identified, indicating a consistent linear trend with no interruptions or statistically significant shifts in the rate of change in deprescribing prevalence. ARIMA modeling found that the publication of deprescribing guidelines had no impact on deprescribing trends. Conclusions Despite the high use of PIMs, and the publication of the STOPPFrail, PPI, and antipsychotic deprescribing guidelines, deprescribing rates remained low and even decreased. These findings emphasize the importance of implementation efforts that go well beyond guideline publications to effectively change deprescribing practices.
PubDate: 2025-03-20
- Prescription and Non-prescription Medication Pill Burdens and Their
Associations with Health-Related Quality of Life in Older Adults: A
Cross-Sectional Study-
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Abstract: Background Polypharmacy is associated with reduced health-related quality of life (HRQoL). This study explores the association between prescription and non-prescription medication pill burdens, independent of underlying morbidity, on HRQoL in an older adult population. Methods Data from the final intervention year of the ASPirin in Reducing Events in the Elderly (ASPREE) randomized trial in older adults from Australia and the USA, were analyzed cross-sectionally. Participants reported daily prescription and non-prescription pill counts at the final trial visit. HRQoL was assessed using the 12-Item Short-Form instrument (SF-12) and summarized into the physical component summary (PCS) score and mental component summary (MCS) score, where lower scores reflect poorer HRQoL. Multivariable regression, adjusted for covariates, was used to examine the relationships of categorized prescription and non-prescription pill counts with PCS and MCS separately. Results 15,165 participants responded to the question about prescription use and 15,727 for non-prescriptions (mean age = 80 years). Compared with non-users of prescription medications, lower mean PCS scores and larger reductions in scores were seen as prescription medication pill burden increased from 1–3, 4–6, 7–9, to ≥ 10 pills (− 1.7, − 4.5, − 7.6, and − 10.9, respectively, p < 0.001). A similar relationship, but of lesser magnitude, was observed with non-prescription medication pill burden, where the mean PCS was lower by − 0.2 for 1–3 pills (p = 0.494), − 1.8 for 4–6 (p < 0.001), and − 1.9 for ≥ 7 pills (p < 0.001), compared with non-users. No significant association was observed between prescription or non-prescription medication pill burdens and MCS. Conclusions Prescription and non-prescription medication pill burdens are independently associated with reduced physical, but not mental, HRQoL in older adults.
PubDate: 2025-03-19
- A Post Hoc Analysis of Older Patients with Metastatic Colorectal Cancer
Receiving Oxaliplatin-Based Chemotherapy Plus Bevacizumab: The Randomized
Obelics Study-
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Abstract: Background Phase II trials and subgroup analyses of clinical studies suggest that bevacizumab plus an oxaliplatin-based chemotherapy doublet is effective and tolerable in fit older patients with metastatic colorectal cancer (mCRC). Objective To evaluate the influence of age on the incidence of side effects and efficacy of this combination in patients with mCRC randomized in the prospective phase III OBELICS study. Methods In total, 230 patients with Eastern Cooperative Oncology Group (ECOG) performance status (PS) 0 out of 1 were retrieved on the basis of age (190 < 70 years and 40 ≥ 70 years). They received bevacizumab 5 mg/kg administered either on the same day as chemotherapy (standard arm) or 4 days before chemotherapy (experimental arm) and oxaliplatin 85 mg/m2 on day 1, plus capecitabine 1000 mg/m2 twice a day (bid) orally on days 1–10 or levofolinic acid, 200 mg/m2, bolus 5-fluorouracil (5-FU) 400 mg/m2, and a 46-h intravenous infusion of 5-FU 2400 mg/m2, every 14 days; oxaliplatin was discontinued after 12 cycles. The primary end point was the overall response rate (ORR). Results Efficacy and toxicity analyses are reported in aggregate form because there were no statistically significant differences between the two arms. Patient characteristics are well balanced between older and younger patients. No difference in ORR was observed between the two groups (50% for the older patients versus 57.9% for the younger ones; p = 0.36). The median PFS was 10.8 (95% confidence interval [CI], 9.9–12.2) and 11.3 (95% CI 8.3–13.0) months, respectively, for subjects younger than 70 years and those aged ≥ 70 years, with an adjusted hazard ratio (HR) of 1.16 (95% CI 0.80–1.68; p = 0.43). The median OS was 26.2 (95% CI 23.3–32.7) for the former and 23.2 (95% CI 17.3–35.3) months for the latter, respectively, with an adjusted HR of 1.60 (95% CI 1.08–2.37; p = 0.027). Considering all forms of toxicity, the most severe ones were not statistically different between the two groups (65% for the older patients and 60.6% for the younger ones, p = 0.61). Conclusions Bevacizumab plus an oxaliplatin-based chemotherapy doublet were effective in older patients randomized in the OBELICS trial, and the adverse event profile was not dissimilar from that of younger patients; no new safety concerns were identified. This post hoc analysis confirms that fit older patients with mCRC should be considered for treatment with this regimen.
PubDate: 2025-03-16
- Impact of Disease-Modifying Antirheumatic Drugs on Cognitive Function in
Older Adults with Rheumatoid Arthritis-
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Abstract: Cognitive impairment poses significant challenges for aging populations. Systemic inflammation, a hallmark of rheumatoid arthritis (RA), has been implicated in neurodegeneration through mechanisms including blood–brain barrier disruption, microglial activation, and cytokine-mediated neuronal damage. This review examines the potential impact of disease-modifying antirheumatic drugs (DMARDs) on cognitive function in RA, focusing on the inflammatory pathways linking systemic inflammation to neuroinflammation and cognitive decline. DMARDs, categorized into conventional synthetic (csDMARDs), biologic (bDMARDs), and targeted synthetic (tsDMARDs) classes, modulate immune responses through distinct mechanisms. Evidence suggests that DMARDs, particularly bDMARDs targeting proinflammatory cytokines such as TNF-α and IL-6, may mitigate neuroinflammatory processes and preserve cognitive function. However, the cognitive impact of csDMARDs such as methotrexate is complex, with conflicting reports regarding its role in vascular dementia. Emerging therapies such as Janus kinase inhibitors (JAK-i) offer promise in modulating central inflammation, though clinical evidence remains limited. While some studies highlight protective effects of DMARDs against dementia, findings are inconsistent, hindered by heterogeneity in study design, patient demographics, and cognitive assessment methods. This review underscores the need for personalized treatment strategies, integrating RA management with cognitive health considerations. Future research should prioritize robust, prospective studies with long-term follow-up, incorporating neuroimaging and biomarker analysis to elucidate the mechanisms underpinning DMARD-associated cognitive outcomes. A better understanding of the involved inflammatory pathways in RA and the potential effects of DMARDs could lead to improved therapeutic approaches, enhancing quality of life for patients with RA and potentially benefiting broader strategies in preventing or treating dementia.
PubDate: 2025-03-15
- Trazodone and Risk of Orthostatic Hypotension, Syncope and Falls in
Geriatric Outpatients with Hypertension-
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Abstract: Introduction In older adults, trazodone is frequently prescribed for anxiety and insomnia owing to its perceived greater tolerability in comparison with benzodiazepines. However, it may have hypotensive effects. Aim The aim of this study is to investigate the effects of trazodone on orthostatic blood pressure (BP) response and risk of syncope and falls in hypertensive older adults. Patients and Methods A longitudinal observational study involving patients ≥ 75 years was conducted in two geriatric outpatient clinics in Florence, Italy. At baseline, participants underwent a 3-min active stand test, office BP measurement and home and ambulatory BP monitoring. At follow-up, syncope and falls were recorded. Results Among 123 participants (mean age 81 years, 59% female), 12 (10%) reported regular trazodone use. Trazodone users showed lower office diastolic BP (71.8 versus 80.1 mmHg, p = 0.042), a greater systolic and diastolic BP reduction immediately after standing (ΔsystolicT0 23.8 versus 14.3 mmHg, p = 0.037; ΔdiastolicT0 8.9 versus 1.6 mmHg, p = 0.004) and a greater diastolic BP reduction after 1-min standing (ΔdiastolicT1 6.5 versus 0 mmHg, p = 0.029). No differences were reported for home or ambulatory BP. Incidence of syncope and falls was 25%, with a significantly higher rate in patients receiving trazodone (58.3% versus 21.2%, p = 0.001). Trazodone use predicted syncope and falls independently of age, disability and fall history. This association was not confirmed when adjusting for dementia diagnosis. BP values were not associated with the study outcome. Conclusions In older hypertensive outpatients, trazodone is associated with a greater orthostatic BP drop and may predispose them to an increased risk of syncope and falls.
PubDate: 2025-03-11
- Medicine Optimisation and Deprescribing Intervention Outcomes for Older
People with Dementia or Mild Cognitive Impairment: A Systematic Review-
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Abstract: Background Polypharmacy is common amongst older people with dementia or mild cognitive impairment (MCI), increasing the risk of medication-related harm. Medicine optimisation and deprescribing to reduce polypharmacy is considered feasible, safe and can lead to improved health. However, for those living with dementia or MCI, this can be challenging. This systematic review aimed to summarise the evidence on the outcomes of medicine optimisation and deprescribing interventions for older people with dementia or MCI. Methods Literature was searched using CINAHL, Embase, Medline, PsychINFO, Web of Science and the Cochrane Library from database inception to January 2024. Papers reporting data specific to people with dementia or MCI from medicine optimisation and deprescribing interventional research studies of any design and in any setting were included. A narrative synthesis was conducted owing to heterogeneity of study designs and outcomes. Quality was assessed using the Mixed Methods Appraisal Tool. Results A total of 32 papers reporting on 28 studies were included, with samples ranging from 29 to 17,933 patients and a mean patient age ranging from 74 to 88 years. Of the studies, 60% were undertaken in long-term care settings. Involvement of patients and/or carers in interventions was limited. Papers were grouped as either incorporating a medication review component (n = 13), education component (n = 5) or both (n = 14). Studies primarily focussed on medication-related outcomes, generally showing a positive effect on decreasing the number and improving appropriateness of medications. Fewer papers reported clinical outcomes (behavioural and psychological symptoms of dementia, falls, quality of life and cognition) with mixed findings. A reduction or no change in mortality or hospital attendance demonstrated safety of the interventions in the few papers reporting these outcomes. The quality of the evidence was mixed. Conclusions Medicine optimisation and deprescribing interventions generally reduced the number and increased the appropriateness of medications, and although less frequently reported, these interventions seemed to be safe and showed an absence of worsening of clinical outcomes. This review highlights a need for further research, particularly in people with dementia or MCI living at home, with more focus on clinical outcomes and a greater involvement of patients and informal carers. Protocol Registration The protocol was published in the International Prospective Register of Systematic Reviews (PROSPERO) [Ref: CRD42023398139].
PubDate: 2025-03-11
- Dementia Medications and Their Association with Pain Medication Use in
Medicare Beneficiaries with Alzheimer’s Disease/Alzheimer’s
Disease-Related Dementias and Chronic Pain-
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Abstract: Introduction Chronic pain is prevalent among older adults with Alzheimer’s disease (AD) and Alzheimer’s disease-related dementias (ADRD). Memantine and acetylcholinesterase inhibitors (ACHEI; donepezil, rivastigmine, and galantamine) are approved for the treatment of dementia symptoms and may also have analgesic properties. However, findings on the clinical utility of these dementia medications for chronic pain treatment are mixed, and little is known about differences in the use of pain medication according to whether an older adult with AD/ADRD is using dementia medications. Methods We selected a 20% national sample of Medicare enrollees with a diagnosis of AD/ADRD and chronic pain in 2020. We calculated the odds of having any pain management prescription (opioids, serotonin and norepinephrine reuptake, gapapentinoids, or non-steroidal anti-inflammatory drugs), having an opioid prescription, and having a long-term (≥ 90 days) opioid prescription, by dementia medication (none, memantine, ACHEI, or memantine and ACHEI). Results Among 103,564 patients, 5.5% received a memantine prescription, 14.4% received an ACHEI prescription, and 8.6% received a prescription for both. Over 70% of all patients had a pain management prescription. The percentage of patients who had an opioid prescription ranged from 54.5% for those without a dementia medication prescription to 44.0% for those with a prescription for both memantine and ACHEI. Similarly, the percentage of patients who had a long-term opioid prescription was highest for those without a dementia medication prescription (12.2%) and lowest for those with a prescription for both memantine and ACHEI (8.8%). Having a prescription for memantine only was associated with lower odds of any pain management prescription (odds ratio [OR]: 0.94; 95% confidence interval [CI]: 0.88–1.00; p < 0.05). Having a prescription for either memantine (OR: 0.79; 95% CI 0.75–0.84), ACHEI (OR: 0.85; 95% CI 0.82–0.89), or both (OR: 0.75; 95% CI 0.72–0.79) was associated with lower odds of having an opioid prescription (p < 0.05). Lastly, having a prescription for either memantine (OR: 0.85; 95% CI 0.77–0.94), ACHEI (OR: 0.92; 95% CI 0.86–0.98), or both (OR: 0.83; 95% CI 0.77–0.90) was associated with lower odds of having a long-term opioid prescription. Discussion Older adults with co-occurring AD/ADRD and chronic pain who were on dementia medications had lower odds of being prescribed opioid analgesics. Memantine and ACHEIs should be explored as potential opioid-sparing medications for older adults with AD/ADRD, given their relatively safe profiles. Future studies are needed to examine repurposing dementia medications for pain treatment.
PubDate: 2025-02-26
- Executive Summary: Treatment of Osteoporosis and Osteoarthritis in the
Oldest Old-
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Abstract: This is the executive summary of a work by the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO) (Nicholas Fuggle et al. in Drugs, 2024).
PubDate: 2025-02-24
- Safety and Efficacy of Sodium-Glucose Cotransporter 2 Inhibitors in Older
Adults with Variable Disease States: A Meta-analysis of Large
Placebo-Controlled Trials-
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Abstract: Background Recent guidelines recommend the use of sodium-glucose cotransporter 2 (SGLT-2) inhibitors (SGLT2i) in patients suffering from cardiorenal diseases. However, the safety and efficacy of SGLT2i in older adults with atherosclerotic cardiovascular disease (ASCVD), heart failure (HF), and chronic kidney disease (CKD) remain unclear. Methods Online databases were queried from inception to 11 July 2023 to identify primary or secondary analyses for inclusion. Efficacy outcomes included all-cause mortality, cardiovascular (CV) death, hospitalization for heart failure (HHF), major adverse cardiac events (MACE), CV death/HHF composite, and cardiorenal composite events. Safety endpoints included acute kidney injury (AKI), serious adverse events, genital infections, limb amputation, fractures, urinary tract infections (UTI), and volume depletion. Data were pooled using a random-effects model to derive risk ratios (RRs) and 95% confidence intervals (CIs). Results Eight trials with 32,541 older adults identified in primary or secondary analyses were included. In older adults, SGLT2i reduced the risk of all-cause mortality (RR 0.88; 95% CI 0.83– 0.95), CV death (RR 0.82; 95% CI 0.74–0.92), HHF (RR 0.72; 95% CI 0.66–0.79), MACE (RR 0.87; 95% CI 0.77–0.99), CV death/HHF composite (RR 0.78; 95% CI 0.70–0.88), and cardiorenal composite events (RR 0.77; 95% CI 0.70–0.85). For safety endpoints, SGLT2i decreased the risk of serious adverse events (RR 0.92; 95% CI 0.89–0.95) and increased the risk of genital infections (RR 3.48; 95% CI 2.58–4.69). Conclusions This analysis of randomized trials demonstrates that SGLT2i are efficacious in older adults. However, since older individuals are often underrepresented in most clinical trials, further research targeting this growing demographic is essential.
PubDate: 2025-02-22
- Factors Influencing General Practitioners’ Deprescribing Decisions for
Older Adults, with Insights into Frailty: a Qualitative Study in Greek
Primary Care-
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Abstract: Introduction Polypharmacy is increasing among older individuals worldwide. Deprescribing has been suggested as a strategy to reduce polypharmacy, but it has had a limited impact. Objective This study investigated the facilitators and barriers to deprescribing in older adults, as perceived by primary care general practitioners, focusing particularly on factors influencing deprescribing in frail individuals. Methods A qualitative approach was employed and semistructured interviews were conducted between 9 April and 29 May 2024 with a sample of 30 general practitioners working in primary care facilities in Crete, Greece. The interviews were recorded and transcribed verbatim. Thematic analysis was performed on the basis of the Theoretical Domains Framework. Results Several barriers to deprescribing were revealed, including a lack of expertise and motivation, inadequate communication skills, time constraints, and negative beliefs toward deprescribing held by physicians and patients. The lack of an established role for general practitioners in primary care, the absence of a national initiative targeting polypharmacy, and the influence of pharmacists and pharmaceutical representatives were highlighted as challenges. The identified facilitators included the incorporation of deprescribing recommendations and considerations for frail patients into guidelines, fostering a strong doctor–patient relationship, promoting shared decision-making, facilitating effective collaboration with caregivers, and utilizing nonpharmacological therapy. Conclusions General practitioners encounter both barriers and facilitators when making deprescribing decisions for older adults, particularly those with frailty syndrome. Researchers and policymakers can use the findings of this research to guide future interventions and promote successful deprescribing practices.
PubDate: 2025-02-21
- Safety Study of Anticoagulants for Preventing Deep Venous Thrombosis after
Intracerebral Hemorrhage: Data from the Chinese Stroke Center Alliance-
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Abstract: Objective The use of anticoagulants to prevent deep vein thrombosis (DVT) after intracerebral hemorrhage (ICH) remains controversial. This study aims to evaluate the safety of anticoagulants in preventing DVT in patients with ICH. Methods Data were sourced from the Chinese Stroke Center Alliance. The primary outcomes include in-hospital mortality, intracranial hematoma evacuation, and hematoma expansion. Absolute standardized differences (ASD) are used to assess differences between groups, and multivariate logistic regression analysis is employed to analyze correlations. Platelet counts and international normalized ratio (INR) were examined within subgroups. Propensity score matching (PSM) is used for sensitivity analysis. Results A total of 56,633 patients with ICH were finally enrolled. Multivariate logistic regression analysis revealed that anticoagulant use correlated with reduced in-hospital mortality and hematoma expansion (OR: 0.59, 95% CI: 0.50–0.69, p < 0.001 and OR: 0.55, 95% CI: 0.41–0.73, p < 0.001), while no association was observed with intracranial hematoma evacuation clearance (OR: 1.00, 95% CI: 0.93–1.08, p = 0.941). Subgroup analysis revealed an increased risk of intracranial hematoma evacuation with anticoagulant use when INR>1.7 (OR: 1.47, 95% CI: 1.15–1.89, p = 0.002), but not of in-hospital mortality (OR: 1.20, 95% CI: 0.78–1.85, p = 0.409) or hematoma expansion (OR: 0.66, 95% CI: 0.19–2.25, p = 0.503). PSM yielded consistent outcomes. Conclusions Post-ICH anticoagulant therapy to prevent DVT is safe, posing no heightened risk of in-hospital mortality, intracranial hematoma evacuation, or hematoma expansion. However, caution is warranted in patients with coagulopathies.
PubDate: 2025-02-20
- Antidepressants to Manage Osteoarthritic Pain: The Value of Pain
Phenotyping-
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Abstract: Osteoarthritis (OA) is a chronic condition in which pain significantly affects quality of life, often leading to reduced physical activity and disability. Globally, an estimated 595 million people are affected, with the numbers likely to increase owing to an aging population and rising obesity rates. Effective pain management is crucial, yet current treatments, such as nonsteroidal anti-inflammatory drugs (NSAIDs) and opioids, often provide limited relief and come with risks. One reason for this limited success is the insufficient recognition of the importance of psychosocial factors and heterogeneity of patients with OA (such as anxiety and depression), which can exacerbate pain and its impacts. The variability in patient pain experiences highlights the potential value of pain phenotyping, which involves a comprehensive assessment of pain characteristics to tailor treatments to individual needs. Antidepressants, particularly serotonin–norepinephrine reuptake inhibitors (SNRIs), show promise in alleviating both psychological symptoms and OA-related pain, but their effectiveness varies among individuals. Therefore, further research into standardized pain phenotyping methods and their integration into antidepressant treatment is needed to improve efficacy and minimize side effects through more personalized approaches.
PubDate: 2025-02-20
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