Carotid endarterectomy for stroke prevention in older people.

The efficacy of endarterectomy for patients with symptomatic high-grade stenosis of the extracranial carotid artery has been firmly established. Those with asymptomatic carotid disease may also be candidates for the operation. A thorough understanding of the benefits and risks of the operation for the individual patient is necessary in determining whether to recommend the operation.     

Antithrombotic management of atrial fibrillation for stroke prevention in older people.

Atrial fibrillation (AF) is a common cardiac condition in the elderly population. The primary concern in individuals with AF is the risk of stroke. The management of AF for stroke prevention requires an understanding of the relative risks and benefits of antithrombotic therapy. Numerous randomized clinical trials have improved tremendously our understanding of the relative merits of anticoagulation and aspirin, and indicate that anticoagulation is the appropriate treatment for the majority of individuals with AF. In patients who have contraindications to anticoagulation, aspirin is recommended.     

老年甲状腺功能减退症的管理

老年人的下丘脑-垂体-甲状腺轴功能下降.老年甲状腺功能减退症(甲减)患病率高,在诊断和治疗方面存在诸多的争议,是目前的研究热点.老年甲减的临床表现不典型,往往合并多种疾病.亚临床甲状腺功能减退对老年人心血管、认知、生活质量和寿命的影响和左旋甲状腺素片(L-T4)替代治疗获益不确定.年龄特异性促甲状腺激素(TSH)参考值...     

Management of poststroke depression in older people.

Depression is a common and under-recognized cause of suffering after stroke. Poststroke depression (PSD) is associated with poorer stroke recovery and increased mortality. Much published research focuses on controversies about demographic and lesion-related associations with PSD and the extent to which it is different from primary depressive illness without stroke. Methodological and population differences across studies account for at least part of the inconsistent research findings about PSD. Rates of treatment for PSD appear to be extremely low. Surprisingly little evidence is available about the effectiveness of various treatments for PSD, and randomized controlled clinical trials are needed. This article summarizes epidemiologic data about PSD, highlights stroke-related and demographic features that increase risk, and reviews the literature on treatment.     

Efficacy of anticoagulation for secondary stroke prevention in older people with non-valvular atrial fibrillation: a prospective case series study

BACKGROUND AND PURPOSE: Despite large randomised trials that demonstrated the efficacy of oral anticoagulants in the primary and secondary prevention of stroke in patients with non-valvular atrial fibrillation (AF), anticoagulation therapy remains largely under-used in older patients, who are at risk of first ever or recurrent stroke. The aim of the present study was to assess the influence of anticoagulation therapy on long-term prognosis in the oldest old stroke patients with AF after adjusting for baseline risk factors. METHODS: We evaluated prospectively a consecutive series of 207 older people (>75 years) with AF and first ever ischaemic stroke. During the follow-up period (mean 88.4 months, range 3-120), the study population was under either oral anticoagulants (n = 72) or aspirin (n = 135). Death and recurrent vascular events (stroke and systemic embolism) were documented. Statistical analyses were performed by means of the Kaplan-Meier product limit method and the Cox proportional hazards model. RESULTS: The cumulative 10 year mortality and recurrence rate were 92.5% (95% CI 85.7-99.3) and 66.1% (95% CI 43.1-89.1), respectively. Cox regression analysis revealed increasing age, functional dependency at hospital discharge and antiplatelet versus anticoagulation therapy as independent determinants of mortality. Antiplatelet versus anticoagulation therapy was the sole determinant of vascular recurrence. Anticoagulation was associated with decreased risk of death (hazards ratio (HR) 0.47, 95% CI 0.31-0.72, P = 0.001)) and recurrent thromboembolism (HR 0.31, 95% CI 0.16-0.62, P = 0.002). CONCLUSIONS: Our results suggest that the benefits of anticoagulation for secondary stroke prevention in AF patients extend to the oldest old. Prospective randomised clinical trials are needed to verify the potential benefit of anticoagulation in such patients.     

Management of high cholesterol levels in older people

The management of hypercholesterolemia in older adults still represents a challenge in clinical medicine. The pathophysiological alterations of cholesterol metabolism associated with aging are still incompletely understood, even if epidemiological evidence suggests that serum cholesterol levels increase with ongoing age, possibly with a plateau after the age of 80 years. Age is also one of the main determinants of cardiovascular disease, according to all cardiovascular risk estimate tools. Cholesterol‐lowering treatment, therefore, would be expected to bring significant protection, even in these patients. Unfortunately, direct experimental evidence is extremely limited, particularly in the very old age strata of the population; a clinical benefit still seems to be present, but the risk for drug‐related adverse events is clearly higher. At any rate, at the present time, definite guidelines for the correct management of hypercholesterolemia in older patients are not available. Therefore, the decision whether or not a pharmacological treatment should be set up, and the choice of the drug, need to be tailored to the individual patient, and requires accurate clinical judgment. The specific aspects of frailty and disability, along with the actual age of the patients, have to be considered together, with a comprehensive assessment approach. The present review summarizes the evidence regarding the modifications of cholesterol metabolism in older patients, the impact of lipid‐lowering drugs on cardiovascular outcomes and focuses on the considerations that can help to define the most appropriate treatment strategy, in view of the individual functional profile. Geriatr Gerontol Int 2019; 19: 375–383 .     

Dizziness in older people.

Patients use the term dizziness to describe a sensation of altered orientation in space. Because visual, proprioceptive, somatosensory and vestibular signals provide the main information about the position of the head and body in space, damage to any of these systems can lead to a complaint of dizziness. Changes in the brain centers that integrate these orienting signals can also result in a sensation of dizziness. This review focuses on the pathophysiology, diagnosis, and management of the common causes of dizziness in older people.     

Treatment of hypertension and prevention of ischemic stroke

Data clearly indicate that treatment with antihypertensive drugs reduces the incidence of all strokes in men (by 34%), women (by 38%), elderly persons (by 36%), including those older than 80 years (by 34%), younger persons, those with systolic and diastolic hypertension, persons with isolated systolic hypertension, and in those with a history of stroke or transient ischemic attack (by 28%). Blood pressure should be reduced to less than 140/90 mm Hg. The overall data also suggest that reduction of stroke in persons with hypertension is related more to a reduction in blood pressure than to the type of antihypertensive drugs used.     

Giardia in older people.

CASE REPORTS: We report two cases of giardiasis in elderly women. Neither patient had been abroad recently and neither had diarrhoea at the time of diagnosis. In the first case, an extensive gastrointestinal cancer work-up was carried out before the diagnosis was made. CONCLUSION: It is important to consider possible infective causes in older patients who have anaemia and weight loss.     

Pharmacologic interventions for prevention of delirium in hospitalized older people: A meta-analysis

IntroductionTo comprehensively assess the effects of pharmacologic interventions for prevention of delirium in hospitalized older people.Materials and methodsA systematic review with meta-analysis following Preferred Reporting Items for Systematic reviews and Meta-Analyses methodology was performed. Hospitalized people aged 65 and older, recruited to randomized controlled clinical trials. The electronic databases MEDLINE, EMBASE, WOS and Cochrane Central Register of Controlled Trials were consulted (March 2019). Predefined criteria were used to determine inclusion of studies and to assess their methodologic quality.Results1855 records were identified in the database, and after removing the duplicates, the titles and abstracts evaluated were 1250 records. Finally, 25 randomized controlled trials contributed to meta-analysis (n = 5820): 1 anti-epileptics (n = 697), 2 anti-inflammatories (n = 615), 4 antipsychotics (n = 1193), 2 cholinesterase inhibitors (n = 87), 13 hypnotics/sedatives (n = 2909), 1 opioids (n = 52), 1 psychostimulants/nootropics (n = 81), 1 yokukansan (n = 186). Olanzapine (RR = 0.36; 95 %CI: 0.24, 0.52; k = 1; n = 400), rivastigmine (RR = 0.36; 95 %CI: 0.15, 0.87; k = 1; n = 62), dexmedetomidine (RR = 0.52; 95 %CI: 0.38, 0.71; I² = 55 %; k = 6; n = 2084), and ramelteon (RR = 0.09; 95 %CI: 0.01, 0.64; k = 1; n = 65) reduced the incidence of delirium compared to placebo/usual care. Only dexmedetomidine was also associated with a shorter duration of delirium (0.70 days reduction) and a lower consumption of psychotropic drugs (48 %). No effect was found in mortality, adverse events, urinary tract infections or post-operative complications.ConclusionsThis meta-analysis suggests that dexmedetomidine is effective in reducing the incidence and duration of delirium in hospitalized older patients. Individual studies reveal effects of ramelteon, olanzapine and rivastigmine on the incidence of delirium but the evidence is insufficient to draw a robust conclusion.     

Treatment for the secondary prevention of stroke in older patients: the influence of dementia status.

OBJECTIVE: To investigate the influence of dementia status on treatment for the secondary prevention of stroke in older patients. DESIGN: Based on patient examinations and medical record review, we investigated the frequency of aspirin and/or warfarin use at hospital discharge for the prevention of recurrent stroke in older patients hospitalized with acute ischemic stroke. SETTING: A large academic medical center. PARTICIPANTS: A cohort of 272 patients, mean age 72.1 +/- 8.5 years. MEASUREMENTS: We performed neurologic examinations and reviewed medical records to investigate the effects of a clinical diagnosis of dementia and other potentially relevant factors on treatment with aspirin or warfarin at hospital discharge. RESULTS: Thirty-one patients (11.4%) were not prescribed aspirin or warfarin at hospital discharge. Logistic regression determined that dementia (odds ratio (OR) = 2.57, 95% confidence interval (CI), 1.04-6.30) was a significant independent determinant of nontreatment with aspirin or warfarin, adjusting for abnormal gait (OR = 2.01, CI, .88-4.59); discharge to a nursing home or other institutional residence (OR = 2.55, CI, .83-7.81); cardiac disease (OR = .39, CI, .16-.95); cortical infarct location (OR = .45, CI, .18-1.10); male sex (OR = .47, CI, .20-1.15); age 80+ (OR = 1.14, CI, .46-2.82) and age 70-79 (OR = .96, CI, .32-2.88) versus age 60-69. CONCLUSIONS: Our results suggest that dementia is a significant independent determinant of nontreatment with aspirin or warfarin when otherwise indicated for the prevention of recurrent stroke. The underutilization of aspirin and warfarin in older stroke patients with dementia may be a modifiable basis for their increased risk of recurrence and death.     

Falls in older people: epidemiology, risk factors and strategies for prevention

Falls are a common and often devastating problem among older people, causing a tremendous amount of morbidity, mortality and use of health care services including premature nursing home admissions. Most of these falls are associated with one or more identifiable risk factors (e.g. weakness, unsteady gait, confusion and certain medications), and research has shown that attention to these risk factors can significantly reduce rates of falling. Considerable evidence now documents that the most effective (and cost-effective) fall reduction programmes have involved systematic fall risk assessment and targeted interventions, exercise programmes and environmental-inspection and hazard-reduction programmes. These findings have been substantiated by careful meta-analysis of large numbers of controlled clinical trials and by consensus panels of experts who have developed evidence-based practice guidelines for fall prevention and management. Medical assessment of fall risks and provision of appropriate interventions are challenging because of the complex nature of falls. Optimal approaches involve interdisciplinary collaboration in assessment and interventions, particularly exercise, attention to co-existing medical conditions and environmental inspection and hazard abatement.     

Management of hypertension in patients with acute stroke

Lowering systemic blood pressure (BP) in patients with acute cerebral infarction may produce clinical deterioration. Because of impaired cerebral autoregulation and the spontaneous fluctuations in BP following stroke, antihypertensive medication should be avoided in patients with acute cerebral infarction unless vital organs such as the heart or kidney are compromised, the diastolic BP rises to 130 mm Hg or greater, or the patient has hypertensive encephalopathy. Brief remarks about BP control in intracerebral hematoma and subarachnoid hemorrhage are also included.     

Arterial hypertension and stroke prevention: an update

High blood pressure (BP) is the most important modifiable risk factor for stroke and other vascular diseases. Evidence from randomized controlled trials supports the use of antihypertensive drugs to lower blood pressure for stroke prevention. There is some evidence that specific classes of antihypertensive drugs have different effects and/or their pharmacological actions differ in patient subgroups. This review evaluates the development of antihypertensive therapies and the latest studies of arterial hypertension and stroke prevention: HOPE trial (ramipril versus placebo), ALLHAT trial (CCB or/ and Angiotensin-Conventing enzyme Inhibitors (ACE-Is) versus diuretic), LIFE trial (losartan versus atenolol), and PROGRESS trial (perindopril or/and indapamide versus placebo). Despite the results of these relevant clinical trails, some aspects still remain unresolved. Future clinical trials on hypertension and stroke prevention should answer the following questions: Does lowering BP reduce stroke risk due to specific drug effect or class effect? Are angiotensin II receptor blockers (ARBs) better than ACE-Is? Should ACE-Is and ARBs be considered routinely for either high-risk stroke patients or patients with history of stroke or transient ischemic attack, irrespective of blood pressure? What is the role of lifestyle in BP control?     

Relationship between social network and hypertension in older people in Spain

INTRODUCTION AND OBJECTIVES: To investigate the association between a patient's social network and hypertension risk in older adults in Spain and to determine whether the nature of the social network is related to a patient's awareness of hypertension, to disease treatment and control, or to adherence to hypertension drug therapy. PATIENTS AND METHOD: Cross-sectional study of 3483 subjects representative of the non-institutionalized Spanish population aged 60 years or more. Logistic regression analysis, adjusted for sex, age, educational level, lifestyle and frequency of medical consultation, was used to derive odds ratios (ORs) for associations between characteristics of the social network (e.g., marital status, cohabitation status, frequency of contact with family members, and frequency of contact with friends and neighbors) and aspects of hypertension. RESULTS: The hypertension risk in married individuals and those living with others was less than in those who were unmarried (OR=0.79; 95% confidence interval [CI] 0.67-0.94) or who lived alone (OR=0,75; 95% CI, 0.61-0.93). Men who saw their friends frequently were more likely to be aware of hypertension (OR=1.57; 95% CI, 1.19-2.07). Women who saw their friends or neighbors frequently were less likely to be aware (OR=0.70; 95% CI, 0.51-0.97). No clear relationship between social network characteristics and other hypertension-related variables was observed. CONCLUSIONS: In older adults, hypertension was associated with aspects of social integration, such as marital and cohabitation status. Among hypertensives, awareness of hypertension was partly related to the frequency of contact with family and friends or neighbors.