Drugs & Aging最新文献

Charcot neuropathic osteoarthropathy (CNO) is a condition that develops in the presence of neuropathy, most commonly diabetes-related neuropathy. Owing to the neuropathy, microtrauma to the bones occur without the individual feeling them. With continued walking, bone inflammation, resorption, microfractures and structural changes occur in the bones, which result in irreversible deformities. Diagnosing this condition is often difficult and requires advanced imaging techniques, such as scintigraphy or magnetic resonance imaging, as X-ray changes may not be specific. Treatment of CNO includes immobilization, offloading, recalcification (supplementation of vitamin D and calcium) and in the most advanced cases, surgical treatment. This narrative review aims to synthesize the recent research and clinical implications relating to Charcot foot to help healthcare professionals to stay up-to-date in this relevant topic.

People with dementia (PWD) are frequently exposed to polypharmacy and potentially inappropriate medication use, in which the risks of medication use outweigh the benefits or the medication is not aligned with treatment goals. Appropriate deprescribing of unnecessary or potentially inappropriate medications is essential to high-quality care for PWD, to avoid iatrogenic harm and improve health and well-being for patients and their care partners. In this article, we review the risks of polypharmacy in PWD and evidence for the safety and efficacy of deprescribing in this population. Building off existing deprescribing frameworks for older adults with multimorbidity and limited life expectancy, we provide a roadmap for deprescribing in PWD that addresses the unique challenges of living dementia, including the variable disease course, high prevalence of distressing behavioral symptoms, and central role of care partners. The steps include: (1) identify potential targets for deprescribing by eliciting medication-related goals and considering tradeoffs, (2) develop a tapering plan, (3) complete additional actions that are necessary before deprescribing, and (4) provide close follow-up. Lastly, we provide evidence-based strategies for communicating with patients and their care partners about deprescribing, adapted from the FRAME tool.

Background and objective: Apixaban is the most prescribed direct-acting oral anticoagulant drug. According to its product information, clearance is only partially renal. However, little is known about the impact of renal function on apixaban pharmacokinetics in real-world settings. The aim of this study was therefore to investigate serum concentrations of apixaban in relation to renal function in acutely hospitalised, older patients.

Methods: The study was conducted with a prospective, observational design. Apixaban-treated patients ≥ 65 years acutely admitted to Haukeland University Hospital in Bergen, Norway, during a four-month period were included. Serum concentrations of apixaban were measured at hospitalization and assessed in relation to glomerular filtration rate (GFR). Spearman rank test was used to investigate correlation between GFR and dose-adjusted serum concentrations of apixaban. In addition, dose-adjusted serum concentrations were compared between GFR subgroups by Mann-Whitney tests.

Results: In total, 36 patients were included (median age 84.5 years, range 68-96 years). Median GFR at admission was 43 ml/min (range 17-119 ml/min). Dose-adjusted apixaban serum concentrations correlated significantly with GFR (Spearman r = - 0.54, p = 0.0008). Compared with patients with GFR > 90 ml/min, apixaban dose-adjusted serum concentrations were 3.3-fold, 1.8-fold and 2.0-fold higher in patients with GFR < 30 ml/min (p = 0.01), 30-59 ml/min (p = 0.04) and 60-89 ml/min (n.s.), respectively.

Conclusions: The study shows that dose-adjusted serum concentration of apixaban significantly correlates with renal function in older, acute hospitalized patients. These real-life data indicate that apixaban-treated patients with GFR < 30 ml/min may require around 70% lower dose than normal to achieve sufficient antithrombotic effect and prevent risk of bleedings.

Introduction: A prescribing cascade occurs when a medication is prescribed to manage a side effect of another medication. Prescribing cascades represent a key component of problematic prescribing and can result in harm to patients, especially older adults with multimorbidity and polypharmacy.

Objective: The objective of this study was to explore factors influencing hospital physicians' recognition of prescribing cascades using the Theoretical Domains Framework (TDF), a validated theory-based qualitative methodology.

Methods: Semi-structured interviews were conducted in May-July 2024 with hospital physicians of all grades. Interviews were audio-recorded and transcribed verbatim. Transcripts underwent conventional and directed content analysis to identify themes and TDF domains.

Results: From 14 interviews, four predominant TDF domains were identified: (i) environmental context and resources: busy work conditions, lack of up-to-date medication lists and limited information technology (IT) infrastructure hinder prescribing cascade recognition; (ii) knowledge: physicians demonstrated limited knowledge of the term 'prescribing cascade' and highlighted education and training deficiencies at undergraduate and postgraduate level; (iii) skills: recognition skills are often developed through experiential learning while working (especially with geriatric medicine consultants) and (iv) social/professional role and identity: physicians perceived themselves as primarily responsible for recognising prescribing cascades, while pharmacists enable their recognition through medication reconciliation, medication review and ward round participation.

Conclusions: This study highlights significant gaps in the knowledge and understanding of prescribing cascades among hospital physicians, as well as potential targets for future intervention. Focused education, integrated IT solutions, and a collaborative physician-pharmacist approach would likely improve prescribing cascade recognition in at-risk older people with multimorbidity and polypharmacy.

Frailty is associated with impaired immune function, functional decline, and increased vulnerability to both infection and adverse medication effects. Recurrent urinary tract infection (rUTI) is a common and burdensome condition among older persons, particularly those living with frailty. Despite this, frail individuals remain underrepresented in clinical research guiding rUTI prevention. This review outlines current evidence on rUTI prevention strategies in older persons living with frailty. It highlights feasible tools for frailty assessment and explores how frailty contributes to infection risk and impacts the effectiveness and safety of preventive interventions. Nonpharmacological strategies-including continence management, minimization of catheter use, hydration support, and carer education-form the foundation of prevention. Locally applied vaginal estrogen is the best-supported pharmacological option in postmenopausal women. Evidence for cranberry products, D-mannose, and probiotics remains inconsistent in frail populations, while methenamine hippurate offers a promising, well-tolerated alternative to antibiotics. Prophylactic antibiotic use may reduce recurrence in selected patients but carries significant risks, including Clostridioides difficile infection and antimicrobial resistance. Clinical decision-making should be guided by individualized risk assessment, careful consideration of treatment burden, and regular reassessment of both benefits and harms. Further research is urgently needed to inform evidence-based prevention strategies for this vulnerable population.

Metformin, traditionally promoted for its efficacy in diabetes, is increasingly appreciated for its geroprotective potential in the development of vascular aging, a key contributor to cardiovascular morbidity. This review aims at understanding the spectrum of mechanisms that govern the amelioration of degenerative processes associated with vascular aging by metformin. Central to this therapeutic promise is the activation of AMPK, which reduces metabolic dysregulation and hence slows vascular senescence. Oxidative stress has been identified as an important mechanism thought to be enhanced by metformin in the preservation of endothelial function and attenuation of arterial stiffening. Besides, metformin has lipid-lowering and antiinflammatory activity, which is critical for reducing arterial rigidity and the development of atherosclerotic plaque. In recent times, both clinical and preclinical studies revealed empirical data that confirmed the effectiveness of metformin in the improvement of endothelial function and the decreasing of arterial stiffness as a part of a reduction in the rates of cardiovascular events. The therapeutic action of the drug goes beyond glycemic control, rendering it a geroprotector potentially suitable for broader application in age-related vascular decline. In light of these findings, the clinical acceptance of metformin as an intervention in vascular aging should be possible and promising. Carefully monitored follow-up studies are needed to optimize dosing, delineate the broad biological effects, and verify long-term benefits, which will underpin metformin's role in the paradigm against age-associated vascular diseases.

Background: Atrial fibrillation (AF) is common in older adults, and anticoagulation is recommended for those aged 75 years and older. Still, many individuals remain untreated due to concerns about the benefit-risk balance, particularly among the frail. This study examines the association of incident ischemic stroke (IS) and major or clinically relevant nonmajor bleeding (MB/CRNMB) on 1-year mortality in older patients receiving oral anticoagulants (OAC).

Methods: This retrospective multicenter study included individuals aged ≥ 75 years with AF, discharged between 2014 and 2018 from three acute geriatric units. Baseline functional and frailty status were collected. OAC use at discharge was identified through review of clinical charts. Data on 1-year survival, IS, and MB/CRNMB were extracted from a centralized database. Associations with 1-year mortality were analyzed using a multivariable Cox model with IS and MB/CRNMB as time-dependent variables.

Results: The study included 1684 patients with AF, median age 86 years (interquartile range 82-90), of whom 59.8% were female. Most patients were frail (67.2%) or prefrail (24.2%). Within 1 year, 609 (36.2%) patients died; there were 50 (2.9%) cases of IS and 79 (4.7%) cases of MB/CRNMB. Multivariable Cox analysis showed that incident MB/CRNMB (hazard ratio, HR: 3.82, 95% confidence intervals, CI 2.68-5.45) and IS (HR: 1.82, 95% CI 1.14-2.90) were independently associated with increased 1-year mortality.

Conclusions: In total, one third of older adults with AF receiving OAC die within a year of discharge. Incident MB/CRNMB was more strongly associated with reduced survival than incident IS, underscoring the clinical complexity of anticoagulation management in this high-risk population.