Antithrombotic drugs in secondary stroke prevention among a community dwelling older population

Impact of Age, Multimorbidity and Frailty on the Prescription of Preventive Antiplatelet Therapy in Older Population

Platelet aggregation inhibitors (PAI) have widely proven their efficiency for the prevention of ischemic cardiovascular events. We aimed to describe PAI prescription in an elderly multimorbid population and to determine the factors that influence their prescription, including the impact of age, comorbidities and frailty, evaluated through a comprehensive geriatric assessment. This cross-sectional study included all patients admitted to the acute geriatric department of a university hospital from November 2016 to January 2017. We included 304 consecutive hospitalized patients aged 88.7 ± 5.5 years. One third of the population was treated with PAI. A total of 133 (43.8%) patients had a history of cardiovascular disease, 77 of whom were on PAI. For 16 patients, no indication was identified. The prescription or the absence of PAI were consistent with medical history in 61.8% of patients. In the multivariate analysis, among the 187 patients with an indication for PAI, neither age (odds ratio (OR) = 1.00; 95% confidence interval (CI): [0.91-1.08], per year of age), nor comorbidities (OR = 0.97; 95% CI: [0.75-1.26], per point of Charlson comorbidity index), nor cognitive disorders (OR = 0.98; 95% CI [0.91-1.06] per point of Mini Mental State Examination), nor malnutrition (OR = 1.07; 95% CI [0.96-1.18], per g/L of albumin) were significantly associated with the therapeutic decision. PAI were less prescribed in primary prevention situations, in patients taking anticoagulants and in patients with a history of bleeding. In conclusion, a third of our older comorbid population of inpatients was taking PAI. PAI prescription was consistent with medical history for 61.8% of patients. Age, multimorbidity and frailty do not appear to have a significant influence on therapeutic decision-making. Further research is needed to confirm such a persistence of cardiovascular preventive strategies in frail older patients from other settings and to assess whether these strategies are associated with a clinical benefit in this specific population.

Association of total serum cholesterol with functional outcome following home care rehabilitation in Italian patients with stroke

BACKGROUND

Stroke is a disabling disease. In elderly populations, stroke is the third leading cause of death and the primary cause of reduction in or loss of functional ability and personal autonomy. Possible associations between levels of total serum cholesterol (TC) and both incidence of stroke and functional outcomes after rehabilitation are still under study.

OBJECTIVE

To detect positive and negative prognostic factors associated with functional outcomes in first-time stroke patients admitted to an integrated home care rehabilitative program.

METHODS

This study enrolled 141 patients with a first-time stroke who were admitted to a home care rehabilitation program. Primary outcome measures were the Barthel activities of daily living (ADL) and mobility indices at the beginning and end of the rehabilitative treatment. The impact of TC and other demographic and clinical variables was analyzed using bivariate and multivariate logistic regression analyses.

RESULTS

Age and Short Portable Mental Status Questionnaire (SPMSQ) score were negatively associated with functional outcome. In contrast, elevated TC was positively associated with a better home rehabilitative treatment outcome. Barthel index score at admission was negatively associated with outcomes assessed by the Barthel ADL index and age with outcomes assessed by the Barthel mobility index. In a multivariate logistic regression analysis, SPMSQ score and elevated TC were significantly associated with outcome. Specifically, higher SPMSQ scores were negatively associated with better rehabilitative treatment outcomes, whereas elevated TC was positively associated.

CONCLUSIONS

Elevated TC seems to be associated with better functional outcomes in patients with first-time stroke.

Secondary Prevention of Stroke in Patients with Atrial Fibrillation: Factors Influencing the Prescription of Oral Anticoagulation at Discharge

BACKGROUND

Oral anticoagulation (OAC) is the only treatment that has shown a significant benefit to reduce the risk of recurrence in patients with ischemic stroke and nonvalvular atrial fibrillation (NVAF). However, OAC is still underused, even at discharge from neurological centers. The objective of this study was to identify the reasons underlying the prescription of OAC at discharge after an ischemic stroke in patients with NVAF.

METHODS

We investigated the reasons why ischemic stroke patients with NVAF were not treated with OAC at discharge from 40 centers located in 5 European countries (Austria, Belgium, France, Italy, and Portugal).

RESULTS

Of 320 ischemic stroke survivors at discharge, 186 (58.1%) received OAC, while 260 (81.3%) patients were theoretically eligible according to guidelines and the absence of contraindications. There were significant differences between countries and the logistic regression analysis found being already under OAC before stroke, having no leukoaraiosis, having no potential contraindication, being younger than 75 years, being married and suffering from angina pectoris as independent predictors of being discharged under OAC.

CONCLUSION

This study suggests that besides patient-related factors, the prescription of OAC is also significantly influenced by the social environment and national practices.

Functional decline in frail community-dwelling stroke patients

Patients who suffer a stroke event are at high risk of functional decline after the post-acute rehabilitation period. The aim of the present study was the evaluation of factors associated with functional decline in a large sample of older patients with stroke living in the community. The study population consisted of all patients admitted to home care programs after a post-acute rehabilitation program--with at least 1 year of follow-up--in twenty-two Italian Home Health Agencies from 2000 to 2002 (n=1338). For the present study we selected 355 (26%) patients with diagnosis of stroke. After 1 year of in-home care program, 149 out of 355 stroke survivors (42%) had presented a worsening in the activities of daily living (ADL) scale score. In the final adjusted model, patients with cognitive impairment (OR 2.59, 95% CI, 1.45-4.64), pressure ulcer (OR 2.74, 95% CI, 1.45-5.18), urinary incontinence (OR 1.64, 95% CI, 1.01-3.29), or hearing impairment (OR 1.83, 95% CI, 1.02-3.29) were more likely to significantly decline in physical functioning after a period of 1 year in-home care program. Our study documents that functional decline of stroke patients was largely dependent on specific subjects' clinical characteristics. Three of four concomitant disabling conditions associated in our sample with functional decline--pressure ulcer, urinary incontinence, hearing--can be prevented and eventually treated or modified. Appropriate post-acute rehabilitation programs and adequate home care interventions focused on the prevention and treatment of these conditions might be correlated to better outcomes in older post-stroke patients.

Use of comprehensive geriatric assessment in older cancer patients: recommendations from the task force on CGA of the International Society of Geriatric Oncology (SIOG)

BACKGROUND

As more and more cancers occur in elderly people, oncologists are increasingly confronted with the necessity of integrating geriatric parameters in the treatment of their patients.

METHODS

The International Society of Geriatric Oncology (SIOG) created a task force to review the evidence on the use of a comprehensive geriatric assessment (CGA) in cancer patients. A systematic review of the evidence was conducted.

RESULTS

Several biological and clinical correlates of aging have been identified. Their relative weight and clinical usefulness is still poorly defined. There is strong evidence that a CGA detects many problems missed by a regular assessment in general geriatric and in cancer patients. There is also strong evidence that a CGA improves function and reduces hospitalization in the elderly. There is heterogeneous evidence that it improves survival and that it is cost-effective. There is corroborative evidence from a few studies conducted in cancer patients. Screening tools exist and were successfully used in settings such as the emergency room, but globally were poorly tested. The article contains recommendations for the use of CGA in research and clinical care for older cancer patients.

CONCLUSIONS

A CGA, with or without screening, and with follow-up, should be used in older cancer patients, in order to detect unaddressed problems, improve their functional status, and possibly their survival. The task force cannot recommend any specific tool or approach above others at this point and general geriatric experience should be used.

The ilSIRENTE study: a prospective cohort study on persons aged 80 years and older living in a mountain community of Central Italy

BACKGROUND AND AIMS

"Invecchiamento e Longevità nel Sirente" (Aging and Longevity in the Sirente geographic area, ilSIRENTE) aims at investigating the socio-demographic, functional, clinical and biological characteristics of all subjects aged 80 years and older residing in a well-defined mountain area of Central Italy.

METHODS

Data are from the baseline evaluation of the ilSIRENTE prospective cohort study. A list of all persons living in the Sirente area was obtained from the Registry Offices of the 13 municipalities involved in the study. Data collection started in December 2003 and was completed in September 2004. Among the 429 residents older than 80 years eligible for the study, 364 accepted to participate (response rate 84%). Participants were assessed by trained staff who collected information on socio-demographic factors, clinical conditions, medication use, physical performance and muscle strength. All participants were also evaluated using the Minimum Data Set for Home Care (MDS-HC) form and a slightly modified version of the "Invecchiare in CHIANTI" study.

RESULTS

The mean age of participants was 85.6 +/- 4.8 years (range 80-102 years), with over 20% of participants aged 90 years or older. More than 65% of participants were women. Most participants (70%) were independent or required limited assistance in performing basic activities of daily living (ADL), whereas 30% of participants were independent in instrumental activities of daily living (IADL). Cognitive function (assessed by the Cognitive Performance Score) was normal in 80% of the sample. Higher degrees of disabilities (defined as the sum of dependencies in ADLs and IADLs) were associated with worse physical performance and lower muscle strength.

CONCLUSIONS

Data on the socio-demographic characteristics and health status of very old people living in the Sirente mountain community are discussed and compared with findings from other epidemiological studies.

Prescription of antithrombotic therapy in older patients hospitalized for transient ischemic attack and ischemic stroke: the GIFA study

BACKGROUND AND PURPOSE

Antithrombotic therapy has been demonstrated as an effective tool for secondary ischemic stroke prevention. Nevertheless, scant data are available on actual prescription of this therapy in clinical practice.

METHODS

A total of 17 337 patients admitted to geriatric and internal medicine wards participating in the study in the 1993 to 1998 survey period were analyzed. Patients with coded diagnoses of ischemic stroke and transient ischemic attack (TIA) were selected. Data recorded included demographic and clinical characteristics and medication prescription during hospital stay and at discharge. Logistic regression analyses were used to identify conditions associated with the prescription of antiplatelet or anticoagulant drugs.

RESULTS

Among 946 patients with diagnosis of stroke or TIA (mean age 78 years), >40% was discharged without antithrombotic prescription. Conditions that made the prescription more unlikely were diagnosis of stroke (odds ratio [OR]: 0.61; 95% confidence interval [CI]: 0.44 to 0.86), presence of anemia (OR: 0.70; 95% CI: 0.49 to 0.98), severe disability (OR: 0.48; 95% CI: 0.30 to 0.75), and cognitive impairment (OR: 0.58; 95% CI: 0.43 to 0.75). There was an independent and additive association of physical and cognitive status with antithrombotic therapy prescription.

CONCLUSIONS

A high rate of patients affected by stroke or TIA are discharged from the hospital without antithrombotic therapy. The most important correlates of the likelihood of not receiving an antithrombotic medication were cognitive and functional status.