Publications by authors named "Mirko Petrovic"

167 Publications

Management of post-acute COVID-19 patients in geriatric rehabilitation: EuGMS guidance.

Eur Geriatr Med 2021 Nov 20. Epub 2021 Nov 20.

Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands.

Purpose: To describe a guidance on the management of post-acute COVID 19 patients in geriatric rehabilitation.

Methods: The guidance is based on guidelines for post-acute COVID-19 geriatric rehabilitation developed in the Netherlands, updated with recent insights from literature, related guidance from other countries and disciplines, and combined with experiences from experts in countries participating in the Geriatric Rehabilitation Special Interest Group of the European Geriatric Medicine Society.

Results: This guidance for post-acute COVID-19 rehabilitation is divided into a section addressing general recommendations for geriatric rehabilitation and a section addressing specific processes and procedures. The Sect. "General recommendations for geriatric rehabilitation" addresses: (1) general requirements for post-acute COVID-19 rehabilitation and (2) critical aspects for quality assurance during COVID-19 pandemic. The Sect. "Specific processes and procedures", addresses the following topics: (1) patient selection; (2) admission; (3) treatment; (4) discharge; and (5) follow-up and monitoring.

Conclusion: Providing tailored geriatric rehabilitation treatment to post-acute COVID-19 patients is a challenge for which the guidance is designed to provide support. There is a strong need for additional evidence on COVID-19 geriatric rehabilitation including developing an understanding of risk profiles of older patients living with frailty to develop individualised treatment regimes. The present guidance will be regularly updated based on additional evidence from practice and research.
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http://dx.doi.org/10.1007/s41999-021-00575-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8605452PMC
November 2021

Deprescribing or represcribing: not just a semantic dilemma.

Eur Geriatr Med 2021 Nov 5. Epub 2021 Nov 5.

Section of Geriatrics, Department of Internal Medicine and Paediatrics, Ghent University, Ghent, Belgium.

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http://dx.doi.org/10.1007/s41999-021-00583-4DOI Listing
November 2021

Protocol for a systematic review and meta-analysis assessing the effectiveness of deprescribing in falls prevention in older people.

BMJ Open 2021 Nov 3;11(11):e047190. Epub 2021 Nov 3.

Department of Internal Medicine, Section of Geriatric Medicine, Amsterdam Public Health Research Institute, Amsterdam UMC Location AMC, Amsterdam, The Netherlands

Introduction: One of the known risk factors for fall incidents is the use of specific medications, fall-risk-increasing drugs (FRIDs). However, to date, there is uncertainty related to the effectiveness of deprescribing as a single intervention in falls prevention. Thus, a comprehensive update of the literature focusing on all settings in which older people receive healthcare and all deprescribing interventions is warranted to enhance the current knowledge.

Methods And Analysis: This systematic review protocol follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A systematic search was performed in Cochrane Central Register of Controlled Trials, MEDLINE, Embase and PsycINFO (2 November 2020). We will also search in trial registers. We will include randomised controlled trials, in which any deprescribing intervention is compared with usual care and reports falls as an outcome. Both title and abstract screening and full-text screening will be done by two reviewers. The Cochrane Collaboration revised tool of Risk of Bias will be applied to perform risk of bias assessment. We will categorise the results separately for every setting. If a group of sufficiently comparable studies will be identified, we will perform a meta-analysis applying random effects model. We will investigate heterogeneity using a combination of visual inspection of the forest plot along with consideration of the χ test and the I statistic results. We have prespecified several subgroup and sensitivity analyses.

Ethics And Dissemination: Ethics approval is not applicable for this study since no original data will be collected. The results will be disseminated through peer-reviewed publication and conference presentations. Furthermore, this systematic review will inform the recommendations of working group of polypharmacy and FRIDs of the anticipated World's Falls Guidelines.

Prospero Registration Number: CRD42020218231.
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http://dx.doi.org/10.1136/bmjopen-2020-047190DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8572380PMC
November 2021

Course and Survival of COVID-19 Patients with Comorbidities in Relation to the Trace Element Status at Hospital Admission.

Nutrients 2021 Sep 22;13(10). Epub 2021 Sep 22.

Institute of Experimental Endocrinology, Charité Universitätsmedizin, Hessische Straße 3-4, 10115 Berlin, Germany.

Selenium (Se) and zinc (Zn) are essential trace elements needed for appropriate immune system responses, cell signalling and anti-viral defence. A cross-sectional observational study was conducted at two hospitals in Ghent, Belgium, to investigate whether Se and/or Zn deficiency upon hospital admission correlates to disease severity and mortality risk in COVID-19 patients with or without co-morbidities. Trace element concentrations along with additional biomarkers were determined in serum or plasma and associated to disease severity and outcome. An insufficient Se and/or Zn status upon hospital admission was associated with a higher mortality rate and a more severe disease course in the entire study group, especially in the senior population. In comparison to healthy European adults, the patients displayed strongly depressed total Se (mean ± SD: 59.2 ± 20.6 vs. 84.4 ± 23.4 µg L) and SELENOP (mean ± SD: 2.2 ± 1.9 vs. 4.3 ± 1.0 mg L) concentrations at hospital admission. Particularly strong associations were observed for death risk of cancer, diabetes and chronic cardiac disease patients with low Se status, and of diabetes and obese patients with Zn deficiency. A composite biomarker based on serum or plasma Se, SELENOP and Zn at hospital admission proved to be a reliable tool to predict severe COVID-19 course and death, or mild disease course. We conclude that trace element assessment at hospital admission may contribute to a better stratification of patients with COVID-19 and other similar infectious diseases, support clinical care, therapeutic interventions and adjuvant supplementation needs, and may prove of particular relevance for patients with relevant comorbidities.
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http://dx.doi.org/10.3390/nu13103304DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8541297PMC
September 2021

Underrepresentation of older adults in clinical trials on COVID-19 vaccines: A systematic review.

Ageing Res Rev 2021 11 3;71:101455. Epub 2021 Sep 3.

Geriatria, Accettazione geriatrica e Centro di ricerca per l'invecchiamento, IRCCS INRCA, Ancona, Italy.

During the COVID-19 pandemic older subjects have been disproportionately affected by the disease. Vaccination is a fundamental intervention to prevent the negative consequences of COVID-19, but it is not known if the needs and vulnerabilities of older people are adequately addressed by their inclusion in randomized clinical trials (RCTs) evaluating the efficacy of vaccines for COVID-19. Given this background, we aimed to evaluate if current and ongoing phase II-III RCTs evaluating the efficacy of COVID-19 vaccines included a representative sample of older people. A systematic literature search in PubMed and Clinicaltrials.gov was performed until May 01st, 2021. Among 474 abstracts initially retrieved, 20 RCTs (ten already published, ten ongoing) were included. In the ten studies already published, the mean age of participants was 45.2 ± 11.9 years and only 9.83% of the participants were more than 65 years, 1.66% more than 75 years and less than 1% (0.55%) more than 85 years. In the ten ongoing RCTs, many of the studies aimed at including participants older than 18 years, with one study including participants between 18 and 84 years, and two between 21 and 100 years. In conclusion, our systematic review demonstrates that in published and ongoing phase II-III randomized clinical trials evaluating the efficacy of COVID-19 vaccines only a tiny fraction of the most vulnerable group of older people was included, although they clearly were the first population that had to be vaccinated.
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http://dx.doi.org/10.1016/j.arr.2021.101455DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8413602PMC
November 2021

Use of Drugs with Anticholinergic Properties at Hospital Admission Associated with Mortality in Older Patients: A Danish Nationwide Register-Based Cohort Study.

Drugs Real World Outcomes 2021 Aug 19. Epub 2021 Aug 19.

Department of Geriatric Medicine, Odense University Hospital, J.B. Winsløws Vej 4, 5000, Odense C, Denmark.

Background: Use of drugs with anticholinergic properties (DAP) has a negative impact on older people.

Objective: Our aim was to examine the association between DAP at hospital admission and mortality in older patients.

Patients And Methods: We performed a nationwide population-based cohort study including patients aged ≥ 65 years admitted to Danish geriatric medicine departments during 2005-2014. National health registers were used to link with individual-level data. Patients were followed to emigration, death, or study termination (31 December 2015). DAP was defined as medications included in the anticholinergic cognitive burden (ACB) scale, which assigns each DAP a score between 1 and 3. The individual ACB score was calculated and the number of DAP counted. We used Cox proportional-hazard regressions to estimate the crude and adjusted hazard ratios adjusting for age, activities of daily living, marital status, index admission period, BMI, and prior hospitalizations (model 1), and additionally Charlson Comorbidity Index (model 2).

Results: We included 74,589 patients aged (median [IQR]) 83 (77-88) years. Use of one or more DAP (62.5%) was associated with increased mortality compared with those with no use (p < 0.001). In the fully adjusted model 2, compared with no use, higher mortality risks (HR [95% CI]) were seen with ACB score of 2 and number of DAP ≥ 5 for 30-day (1.46 [1.32-1.61] and 1.46 [1.09-1.95]), 1-year (1.34 [1.28-1.41] and 1.48 [1.29-1.70]), and overall mortality (1.27 [1.23-1.31] and 1.44 [1.31-1.59]), respectively.

Conclusions: Use of DAP at hospital admission is associated with short- and long-term mortality in geriatric patients. Deprescribing studies are warranted to study whether the impact on mortality can be attenuated.
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http://dx.doi.org/10.1007/s40801-021-00270-7DOI Listing
August 2021

Development, evaluation and use of COVID-19 vaccines in older adults: Preliminary principles for the pandemic and beyond.

Br J Clin Pharmacol 2021 09 2;87(9):3459-3461. Epub 2021 Aug 2.

Geriatric Subcommittee of the Clinical Division, IUPHAR (International Union of Basic and Clinical Pharmacology), Kansas, USA.

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http://dx.doi.org/10.1111/bcp.14967DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8444940PMC
September 2021

Management of type 2 diabetes mellitus in older adults: eight case studies with focus SGLT-2 inhibitors and metformin.

Acta Clin Belg 2021 Jul 12:1-8. Epub 2021 Jul 12.

Department of Internal Medicine and Paediatrics, Section of Geriatrics, Ghent University, Ghent, Belgium.

: Sodium-glucose co-transporter-2 (SGLT-2) inhibitors have been recently introduced for type 2 diabetes treatment with significant cardiovascular, renal benefits. Yet, they have frequently been refrained in older adults. Metformin is regarded the first-line diabetes therapy for all ages; still it is associated with weight loss and frailty in older adults. We aimed to outline our experience with three oldest-old patients with high cardiovascular risk managed with SGLT-2 inhibitors, and five patients with anorexia/weight loss managed by metformin cessation. : We outlined demographics, comorbidities, geriatric syndromes, functional status, and diabetes duration, and presented the changes in frailty by noting pre-intervention and post-intervention frailty scores. We outlined benefits and side effects related to SGLT-2 inhibitors, and the deprescription reasons and represcription practices of metformin therapy. We gave details on baseline and current diabetes treatment, overall medication regimen, and current status of the patients. : Among the case studies with SGLT-2 inhibitors, two patients were frail and reversed to pre-frailty status after SGLT-2 intervention, while the third patient was and remained robust. All patients had clinical improvements with better blood pressure and glucose control. Among the case studies treated with metformin, all were frail before the cessation of metformin. Four reversed to pre-frailty and one became robust after intervention. : The findings of our case studies suggest considering SGLT-2 inhibitors in patients with accompanying heart failure/high cardiovascular risk factors and cessation of metformin in those with malnutrition/malnutrition risk. These approaches have potential to improve frailty and inappropriate medication use in diabetic older adults.
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http://dx.doi.org/10.1080/17843286.2021.1952379DOI Listing
July 2021

Different aspects of frailty and COVID-19: points to consider in the current pandemic and future ones.

BMC Geriatr 2021 06 27;21(1):389. Epub 2021 Jun 27.

Dr C I Parhon University Hospital, Department of Nephrology, Iasi, Romania.

Background: Older adults at a higher risk of adverse outcomes and mortality if they get infected with Severe acute respiratory syndrome coronavirus 2 (SARS- CoV-2). These undesired outcomes are because ageing is associated with other conditions like multimorbidity, frailty and disability. This paper describes the impact of frailty on coronavirus disease 2019 (COVID-19) management and outcomes. We also try to point out the role of inflamm-ageing, immunosenescence and reduced microbiota diversity in developing a severe form of COVID-19 and a different response to COVID-19 vaccination among older frail adults. Additionally, we attempt to highlight the impact of frailty on intensive care unit (ICU) outcomes, and hence, the rationale behind using frailty as an exclusion criterion for critical care admission. Similarly, the importance of using a time-saving, validated, sensitive, and user-friendly tool for frailty screening in an acute setting as COVID-19 triage. We performed a narrative review. Publications from 1990 to March 2021 were identified by searching the electronic databases MEDLINE, CINAHL and SCOPUS. Based on this search, we have found that in older frail adults, many mechanisms contribute to the severity of COVID-19, particularly cytokine storm; those mechanisms include lower immunological capacity and status of ongoing chronic inflammation and reduced gut microbiota diversity. Higher degrees of frailty were associated with poor outcomes and higher mortality rates during and after ICU admission. Also, the response to COVID-19 vaccination among frail older adults might differ from the general population regarding effectiveness and side effects. Researches also had shown that there are many tools for identifying frailty in an acute setting that could be used in COVID-19 triage, and before ICU admission, the clinical frailty scale (CFS) was the most recommended tool.

Conclusion: Older frail adults have a pre-existing immunopathological base that puts them at a higher risk of undesired outcomes and mortality due to COVID-19 and poor response to COVID-19 vaccination. Also, their admission in ICU should depend on their degree of frailty rather than their chronological age, which is better to be screened using the CFS.
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http://dx.doi.org/10.1186/s12877-021-02316-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8236311PMC
June 2021

New horizons in falls prevention and management for older adults: a global initiative.

Age Ageing 2021 09;50(5):1499-1507

Centre for Innovation in Medical Engineering (CIME), Faculty of Engineering, University of Malaya, Kuala Lumpur, Malaysia.

Background: falls and fall-related injuries are common in older adults, have negative effects both on quality of life and functional independence and are associated with increased morbidity, mortality and health care costs. Current clinical approaches and advice from falls guidelines vary substantially between countries and settings, warranting a standardised approach. At the first World Congress on Falls and Postural Instability in Kuala Lumpur, Malaysia, in December 2019, a worldwide task force of experts in falls in older adults, committed to achieving a global consensus on updating clinical practice guidelines for falls prevention and management by incorporating current and emerging evidence in falls research. Moreover, the importance of taking a person-centred approach and including perspectives from patients, caregivers and other stakeholders was recognised as important components of this endeavour. Finally, the need to specifically include recent developments in e-health was acknowledged, as well as the importance of addressing differences between settings and including developing countries.

Methods: a steering committee was assembled and 10 working Groups were created to provide preliminary evidence-based recommendations. A cross-cutting theme on patient's perspective was also created. In addition, a worldwide multidisciplinary group of experts and stakeholders, to review the proposed recommendations and to participate in a Delphi process to achieve consensus for the final recommendations, was brought together.

Conclusion: in this New Horizons article, the global challenges in falls prevention are depicted, the goals of the worldwide task force are summarised and the conceptual framework for development of a global falls prevention and management guideline is presented.
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http://dx.doi.org/10.1093/ageing/afab076DOI Listing
September 2021

Ghent Older People's Prescriptions Community Pharmacy Screening (GheOPS)-Tool Version 2: Update of a Tool to Detect Drug-Related Problems in Older People in Primary Care.

Drugs Aging 2021 06 3;38(6):523-533. Epub 2021 May 3.

Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, 9000, Ghent, Belgium.

Background: The Ghent Older People's Prescriptions community Pharmacy Screening (GheOPS)-tool was developed in 2016 as a screening tool to detect drug-related problems (DRPs) and to help in performing medication reviews in older people (≥ 65 years).

Objective: This study aimed to revise and update the GheOPS-tool.

Methods: Users' comments were collected to improve the usability and appropriateness of the original GheOPS-tool, followed by a two-round modified Delphi process according to the RAND/UCLA appropriateness method. This included a literature review, a round zero meeting, a first written round (with 15 international and multidisciplinary experts) and a second face-to-face round (with 11 experts) to change, delete or add GheOPS-criteria. An additional third round with 14 community pharmacists was organised to preserve criteria applicable in the current community pharmacy practice.

Results: The updated GheOPS-tool consists of five lists of DRPs and a new addendum containing medications that should be avoided or used with caution in older people with reduced renal function. During the first two rounds, related criteria were grouped, 14 criteria were added and 17 criteria were deleted from the original tool. All criteria were deemed applicable in round 3. This led to a final tool (version 2) with 64 GheOPS-criteria.

Conclusion: GheOPS-criteria were revised and updated according to experts' agreement on their clinical relevance and recent scientific evidence. Future studies should investigate the impact of pharmacist-led medication reviews with GheOPS-tool version 2 on clinical, humanistic and economic outcomes in primary care.
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http://dx.doi.org/10.1007/s40266-021-00862-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8088986PMC
June 2021

An International Consensus List of Potentially Clinically Significant Drug-Drug Interactions in Older People.

J Am Med Dir Assoc 2021 10 24;22(10):2121-2133.e24. Epub 2021 Apr 24.

Clinical Pharmacy Research Group, Louvain Drug Research Institute, Université Catholique de Louvain, Brussels, Belgium; Pharmacy Department, CHU UCL Namur, Université Catholique de Louvain, Yvoir, Belgium. Electronic address:

Objectives: We aimed to establish an explicit list of potentially clinically significant drug-drug interactions (DDIs) in people aged ≥65 years.

Design: A preliminary list of potentially clinically significant DDIs was compiled, based on 154 DDIs identified from literature review. Subsequently, a 2-round online Delphi survey was undertaken with a multidisciplinary expert panel. A consensus meeting and a final round were conducted to validate the final DDI list and the scope of information provided.

Setting And Participants: Twenty nine experts, including geriatricians and clinical pharmacists from 8 European countries.

Measures: For each DDI, in the first 2 rounds, experts were asked to score the severity of potential harm on a 5-point Likert-type scale. DDIs were directly included on the final list if the median score was 4 (major) or 5 (catastrophic). DDIs with a median score of 3 (moderate) were discussed at a consensus meeting and included if ≥75% of participants voted for inclusion in the final round.

Results: Consensus was achieved on 66 potentially clinically significant DDIs (28 had a median score of 4/5 and 48 of 3 in the Delphi survey). Most concerned cardiovascular, antithrombotic, and central nervous system drugs. The final list includes information on the mechanism of interaction, harm, and management. Treatment modification is recommended for three-quarters of DDIs.

Conclusion And Implications: We validated a list of potentially clinically significant DDIs in older people, which can be used in clinical practice and education to support identification and management of DDIs or to assess prevalence in epidemiologic and intervention studies.
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http://dx.doi.org/10.1016/j.jamda.2021.03.019DOI Listing
October 2021

International Validation of the Turkish Inappropriate Medication Use in the Elderly (TIME) Criteria Set: A Delphi Panel Study.

Drugs Aging 2021 06 13;38(6):513-521. Epub 2021 Apr 13.

Section of Geriatrics, Department of Internal Medicine and Paediatrics, Ghent University, Ghent, Belgium.

Objective: Explicit screening tools and implicit evaluation methods have been developed to assist healthcare professionals in the management of pharmacotherapy in older adults. As prescribing habits and locally available medications vary considerably between countries, guides tailored to the needs of specific regions may be required. We aimed to report the results of the international Delphi validation study for the Turkish Inappropriate Medication use in the Elderly (TIME) criteria set, which aims to detect inappropriate prescribing in older adults in Eastern Europe.

Methods: The study was conducted between June 2019 and March 2020. Delphi rounds were conducted by the TIME international working group, which included 11 internationally recognized experts in geriatric pharmacotherapy as Delphi panelists. They were asked to indicate to what extent they agreed or disagreed with each TIME criterion, taking into account both the available evidence and their own experience. We used a five-point Likert scale from 1 (strongly agree) to 5 (strongly disagree) and an online software program (SurveyMonkey) to grade the level of agreement. Criteria with a median value of 1 or 2 and a 75th centile value of 1 or 2 were accepted, and criteria with a median value > 2 were rejected. Those with a median value of 1 or 2 but a 75th centile value > 2 were retained, to be assessed in the following round. The initial list of Delphi criteria comprised 153 TIME items.

Results: After three Delphi rounds, 134 criteria were accepted and seven criteria were rejected, while 12 criteria did not achieve consensus, and so were not included in the final validated set of TIME criteria.

Conclusion: We developed the internationally validated TIME criteria set based on a Delphi process involving international experts. The validation study suggests that the TIME criteria set can be applied in both central and Eastern European settings. Further studies are needed to assess the utility and benefit of the TIME criteria in reducing inappropriate drug use and improving clinical outcomes.
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http://dx.doi.org/10.1007/s40266-021-00855-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8041618PMC
June 2021

Identifying key prescribing cascades in older people (iKASCADE): a transnational initiative on drug safety through a sex and gender lens-rationale and design.

Eur Geriatr Med 2021 06 9;12(3):475-483. Epub 2021 Apr 9.

Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada.

Purpose: To describe the objectives, methods and expected impact of an international consortium (iKASCADE) whose purpose is to improve drug safety for older adults by addressing prescribing cascades through a sex and gender lens.

Methods: To create a comprehensive, internationally relevant inventory of prescribing cascades affecting older adults, the consortium has created a modified Delphi procedure where international experts in prescribing and managing pharmacotherapy for older adults will rank a list of prescribing cascades as to their clinical importance. We will use administrative and clinical data on older adults to evaluate the frequency of prescribing cascades by sex internationally, in the hospital, long-term care and community settings. Finally, we will use semi-structured interviews and realistic, country-specific vignettes, each incorporating a prescribing cascade with identified sex differences, to explore how socially constructed gender roles contribute to the experience, presentation and management of prescribing cascades.

Results: The consortium will synthesize the quantitative and qualitative results to produce a position paper and products-aimed at knowledge users within and outside of academia-designed to elevate the importance of integrating a gender dimension in the identification and prevention of prescribing cascades.

Conclusion: Findings will improve our understanding of how adverse drug events are different between older women and men and inform the development and dissemination of tailored knowledge translation products to reduce the frequency and impact of prescribing cascades.
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http://dx.doi.org/10.1007/s41999-021-00480-wDOI Listing
June 2021

Management of anaphylaxis due to COVID-19 vaccines in the elderly.

Allergy 2021 10;76(10):2952-2964

Regional Ministry of Health of Andalusia, Seville, Spain.

Older adults, especially men and/or those with diabetes, hypertension, and/or obesity, are prone to severe COVID-19. In some countries, older adults, particularly those residing in nursing homes, have been prioritized to receive COVID-19 vaccines due to high risk of death. In very rare instances, the COVID-19 vaccines can induce anaphylaxis, and the management of anaphylaxis in older people should be considered carefully. An ARIA-EAACI-EuGMS (Allergic Rhinitis and its Impact on Asthma, European Academy of Allergy and Clinical Immunology, and European Geriatric Medicine Society) Working Group has proposed some recommendations for older adults receiving the COVID-19 vaccines. Anaphylaxis to COVID-19 vaccines is extremely rare (from 1 per 100,000 to 5 per million injections). Symptoms are similar in younger and older adults but they tend to be more severe in the older patients. Adrenaline is the mainstay treatment and should be readily available. A flowchart is proposed to manage anaphylaxis in the older patients.
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http://dx.doi.org/10.1111/all.14838DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8251336PMC
October 2021

Guidance for appropriate use of psychotropic drugs in older people.

Eur Geriatr Med 2021 06 8;12(3):577-583. Epub 2021 Jan 8.

Department of Geriatrics, Ghent University Hospital, Ghent, Belgium.

Psychotropic drugs are widely prescribed in older people although their use is associated with important risks. In this position paper, we discuss the appropriateness of using these medications in older people in terms of different aspects such as indications, contraindications, dosing, adverse drug reactions, interactions and duration of therapy. Consequently, we discuss different strategies to increase the appropriateness of therapy while formulating some practical recommendations to keep in mind when (de)prescribing psychotropic drugs in older people.
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http://dx.doi.org/10.1007/s41999-020-00439-3DOI Listing
June 2021

STOPPFall (Screening Tool of Older Persons Prescriptions in older adults with high fall risk): a Delphi study by the EuGMS Task and Finish Group on Fall-Risk-Increasing Drugs.

Age Ageing 2021 06;50(4):1189-1199

Department of Internal Medicine, Section of Geriatric Medicine, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.

Background: Healthcare professionals are often reluctant to deprescribe fall-risk-increasing drugs (FRIDs). Lack of knowledge and skills form a significant barrier and furthermore, there is no consensus on which medications are considered as FRIDs despite several systematic reviews. To support clinicians in the management of FRIDs and to facilitate the deprescribing process, STOPPFall (Screening Tool of Older Persons Prescriptions in older adults with high fall risk) and a deprescribing tool were developed by a European expert group.

Methods: STOPPFall was created by two facilitators based on evidence from recent meta-analyses and national fall prevention guidelines in Europe. Twenty-four panellists chose their level of agreement on a Likert scale with the items in the STOPPFall in three Delphi panel rounds. A threshold of 70% was selected for consensus a priori. The panellists were asked whether some agents are more fall-risk-increasing than others within the same pharmacological class. In an additional questionnaire, panellists were asked in which cases deprescribing of FRIDs should be considered and how it should be performed.

Results: The panellists agreed on 14 medication classes to be included in the STOPPFall. They were mostly psychotropic medications. The panellists indicated 18 differences between pharmacological subclasses with regard to fall-risk-increasing properties. Practical deprescribing guidance was developed for STOPPFall medication classes.

Conclusion: STOPPFall was created using an expert Delphi consensus process and combined with a practical deprescribing tool designed to optimise medication review. The effectiveness of these tools in falls prevention should be further evaluated in intervention studies.
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http://dx.doi.org/10.1093/ageing/afaa249DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8244563PMC
June 2021

Routine assessment of cognitive function in older patients with hypertension seen by primary care physicians: why and how-a decision-making support from the working group on 'hypertension and the brain' of the European Society of Hypertension and from the European Geriatric Medicine Society.

J Hypertens 2021 01;39(1):90-100

Center for the Research and Treatment of Arterial Hypertension and Cardiovascular Risk, Serviço de Medicina Interna do Hospital da Senhora da Oliveira, Guimarães.

: The guidelines on hypertension recently published by the European Societies of Hypertension and Cardiology, have acknowledged cognitive function (and its decline) as a hypertension-mediated organ damage. In fact, brain damage can be the only hypertension-mediated organ damage in more than 30% of hypertensive patients, evolving undetected for several years if not appropriately screened; as long as undetected it cannot provide either corrective measures, nor adequate risk stratification of the hypertensive patient.The medical community dealing with older hypertensive patients should have a simple and pragmatic approach to early identify and precisely treat these patients. Both hypertension and cognitive decline are undeniably growing pandemics in developed or epidemiologically transitioning societies. Furthermore, there is a clear-cut connection between exposure to the increased blood pressure and development of cognitive decline.Therefore, a group of experts in the field from the European Society of Hypertension and from the European Geriatric Medicine Society gathered together to answer practical clinical questions that often face the physician when dealing with their hypertensive patients in a routine clinical practice. They elaborated a decision-making approach to help standardize such clinical evaluation.
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http://dx.doi.org/10.1097/HJH.0000000000002621DOI Listing
January 2021

Medications in Post-Acute and Long-Term Care: Challenges and Controversies.

J Am Med Dir Assoc 2021 01 27;22(1):1-5. Epub 2020 Nov 27.

Cecil G. Sheps Center for Health Services Research and Schools of Social Work and Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.

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http://dx.doi.org/10.1016/j.jamda.2020.11.027DOI Listing
January 2021

Geriatric care in European countries where geriatric medicine is still emerging.

Eur Geriatr Med 2021 02 25;12(1):205-211. Epub 2020 Nov 25.

Department of Geriatrics and FHU CARTAGE, CHU de Nancy and INSERM 1116, Université de Lorraine, Nancy, France.

Purpose: Practicing geriatric medicine is a challenging task since it involves working together with other medical doctors while coordinating a multidisciplinary team. Global Europe Initiative (GEI) group within the European Geriatric Medicine Society gathers geriatricians from different regions where geriatrics is underrepresented or still developing to promote initiatives for the advancement of geriatric medicine within these countries.

Methods: Here we present a first effort to describe several aspects that affect practicing geriatric medicine in five different countries: Greece, Portugal, Russia, Turkey, and Tunisia.

Results: We can notice discrepancies between countries concerning all dimensions of geriatrics (recognition, training, educational and professional standards, academic representation, working context).

Conclusions: These differences correspond to the specificities of each country and set the frame where geriatric medicine is going to be developed across Europe. EuGMS with GEI group can provide useful support.
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http://dx.doi.org/10.1007/s41999-020-00419-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7685957PMC
February 2021

Discharge from hospital with newly administered antipsychotics after intensive care unit delirium - Incidence and contributing factors.

J Crit Care 2021 02 2;61:162-167. Epub 2020 Nov 2.

Faculty of Medicine and Health Sciences, Ghent University, Corneel Heymanslaan 10, B9000 Ghent, Belgium; Department of Intensive Care, Ghent University Hospital, Corneel Heymanslaan 10, B9000 Ghent, Belgium.

Purpose: Delirium in the intensive care unit (ICU) is often treated with haloperidol or atypical antipsychotics. Antipsychotic treatment can lead to severe adverse effects and excess mortality. After initiation in the ICU, patients are at risk of having their antipsychotics continued unnecessarily at ICU and hospital discharge. This study aims to determine the incidence of, and risk factors for antipsychotic continuation at hospital discharge after ICU delirium.

Methods: This retrospective observational study was performed in a tertiary care center. Adult patients who received antipsychotics for ICU delirium during 2016 were included. Data was extracted from patient records. After univariate testing, a multivariate binary logistic regression model was used to identify independent risk factors for antipsychotic continuation.

Results: A total of 196 patients were included, of which 104 (53.1%) and 41 (20.9%) had their antipsychotics continued at ICU and hospital discharge respectively. Medical ICU admission (odds ratio [95% confidence interval] 2.97 [1.37-6.41]) and quetiapine treatment (5.81 [1.63-20.83]) were independently associated with antipsychotic continuation at hospital discharge.

Conclusions: Approximately one in five patients were discharged from the hospital with continued antipsychotics. Hospital policies should implement strategies for systematic antipsychotic tapering and better follow-up of antipsychotics at transitions of care.
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http://dx.doi.org/10.1016/j.jcrc.2020.10.030DOI Listing
February 2021

August 2020 Interim EuGMS guidance to prepare European Long-Term Care Facilities for COVID-19.

Eur Geriatr Med 2020 12 3;11(6):899-913. Epub 2020 Nov 3.

Department of Geriatrics, CHRU de Nancy and Inserm DCAC, Université de Lorraine, Nancy, France.

Purpose: The European Geriatric Medicine Society (EuGMS) is launching a second interim guidance whose aim is to prevent the entrance and spread of COVID-19 into long-term care facilities (LTCFs).

Methods: The EuGMS gathered experts to propose a guide of measures to prevent COVID-19 outbreaks in LTCFs. It is based on the specific features of SARS-CoV-2 transmission in LTCFs, residents' needs, and on experiences conducted in the field.

Results: Asymptomatic COVID-19 residents and staff members contribute substantially to the dissemination of COVID-19 infection in LTCFs. An infection prevention and control focal point should be set up in every LTCF for (1) supervising infection prevention and control measures aimed at keeping COVID-19 out of LTCFs, (2) RT-PCR testing of residents, staff members, and visitors with COVID-19 symptoms, even atypical, and (3) isolating subjects either infected or in contact with infected subjects. When a first LCTF resident or staff member is infected, a facility-wide RT-PCR test-retest strategy should be implemented for detecting all SARS-CoV-2 carriers. Testing should continue until no new COVID-19 cases are identified. The isolation of residents should be limited as much as possible and associated with measures aiming at limiting its negative effects on their mental and somatic health status.

Conclusions: An early recognition of symptoms compatible with COVID-19 may help to diagnose COVID-19 residents and staff more promptly. Subsequently, an earlier testing for SARS-CoV-2 symptomatic and asymptomatic LTCF staff and residents will enable the implementation of appropriate infection prevention and control. The negative effects of social isolation in residents should be limited as much as possible.
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http://dx.doi.org/10.1007/s41999-020-00405-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7608456PMC
December 2020

Development of a European consensus from dentists, dental hygienists and physicians on a standard for oral health care in care-dependent older people: An e-Delphi study.

Gerodontology 2021 Mar 18;38(1):41-56. Epub 2020 Oct 18.

Division of Gerodontology and removable Prosthodontics, University Clinics of Dental Medicine, University of Geneva, Geneva, Switzerland.

Objectives: This study aimed to obtain a consensus on oral health policy, access to dental care, oral hygiene measures and training levels.

Background: Poor oral health is widespread in care-dependent older people, but no consensus for a minimum standard of oral health care exists yet.

Methods: The e-Delphi approach was applied to a selected panel of interdisciplinary experts. Data analysis was based on three measurements: (a) ≥70% of experts' opinion fall into category "agree or strongly agree," (b) median score on the 5-point Likert scale ≥4, (c) interquartile range ≤1.

Results: A total of 31 experts from 17 European countries participated in this survey. Agreement was achieved for a compulsory dental examination when an elder is admitted to a long-term care (LTC) facility. Older people should brush their teeth twice/day and regularly clean interproximal spaces and oral mucosa. Dentures should be rinsed after meals and cleaned twice/day. The use of denture cleansing tablets was considered necessary. Dentures should be removed before sleeping and stored dry. A 5000 ppm fluoride toothpaste should be applied daily in elder with high caries risk. A short report on the oral health status of the elder should be included in the geriatric assessment. All experts concluded that the knowledge and the training in oral health care for caregivers and family members of care-dependent older people were imperative.

Conclusions: Using the e-Delphi method, multidisciplinary healthcare professionals from different countries agreed on certain cardinal recommendations for a standard oral health care for care-dependent older people.
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http://dx.doi.org/10.1111/ger.12501DOI Listing
March 2021

EuGMS 2019 Congress report: evidence-based medicine in geriatrics.

Eur Geriatr Med 2020 12 13;11(6):915-918. Epub 2020 Oct 13.

Department of Internal Medicine and Gerontology, Faculty of Medicine, Jagiellonian University, Kraków, Poland.

The 2019 EuGMS Congress "Evidence-Based Medicine in Geriatrics" was held in Krakow, Poland, and attended by over 1600 participants from 64 different countries. A summary and reflection on the congress was presented in the Closing Ceremony by European Academy for Medicine of Aging graduates, and summarised in this article. Keynote lectures, 'state of the art' sessions and symposia presented the evidence relating to different age-related conditions, their prevention, management and treatments. Hot topic areas included frailty and multimorbidity, and evidence-based attempts to address these conditions at different life stages. The field of geriatrics represents unique challenges for evidence-based medicine practice. There is much research going on. Clear leadership is needed to facilitate consensus agreements on standard definitions, methods and relevant outcomes, in collaboration with older people themselves, to maximise the opportunities and benefits of doing this research, and benefiting our patients and society at large.
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http://dx.doi.org/10.1007/s41999-020-00416-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7550771PMC
December 2020

Effectiveness and Safety of Oral Anticoagulants in Older Patients With Atrial Fibrillation: A Systematic Review and Meta-Analysis.

Front Pharmacol 2020 9;11:583311. Epub 2020 Sep 9.

Pharmaceutical Care Unit, Department of Bioanalysis, Ghent University, Ghent, Belgium.

Background And Objective: Atrial fibrillation (AF), the most common cardiac arrhythmia, typically increases with age. Oral anticoagulants (OACs) are the cornerstone of treatment to reduce the associated risk for systemic thromboembolism. Four large randomized controlled trials (RCTs) have shown that non-vitamin K antagonist oral anticoagulants (NOACs) are non-inferior to vitamin K antagonists (VKAs) in preventing stroke and systemic embolism, as well as regarding their risk for major bleeding. However, as vulnerable geriatric patients with AF were largely underrepresented in these trials, physicians are faced with the challenge of choosing the right anticoagulant for geriatric patients in real-life clinical practice. In this vulnerable patient group, NOACs tend to be underused or underdosed due to concerns of excessive fall-related intracranial bleeding, cognitive impairment, multiple drug-drug interactions, low body weight or impaired renal function. As life expectancy continues to rise worldwide, the number of geriatric patients substantially increases. Therefore, there is an urgent need for a critical appraisal of the added value of NOACs in geriatric patients with AF at high thromboembolic and bleeding risk.

Methods And Results: This systematic review provides an overview of the literature on the impact of increased age (≥75 years), multimorbidity, polypharmacy, increased falling risk, frailty and dementia on the effectiveness and safety of NOACs as compared to VKAs, after searching the Medline database. Moreover, a meta-analysis on the impact of increased age ≥75 years old was performed after pooling results from 6 analyses of RCTs and 6 longitudinal observational cohort studies, highlighting the superior effectiveness (hazard ratio (HR) 0.83, 95% confidence interval (CI) [0.74-0.94] for stroke/SE; HR 0.77, 95%CI [0.65-0.92] for mortality) and non-inferior safety (HR 0.93, 95%CI [0.86-1.01] for major bleeding; HR 0.58, 95%CI [0.50-0.67] for intracranial bleeding; HR 1.17, 95%CI [0.99-1.38] for gastrointestinal bleeding) of NOACs versus VKAs in older AF patients.

Conclusion: Across geriatric subgroups, apixaban was consistently associated with the most favourable benefit-risk profile and should therefore be preferred in geriatric patients with AF. However, research gaps on the impact of increased falling risk, frailty and baseline dementia were identified, requiring careful consideration while awaiting more results.
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http://dx.doi.org/10.3389/fphar.2020.583311DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7509201PMC
September 2020

Physical Activity and Exercise in Mild Cognitive Impairment and Dementia: An Umbrella Review of Intervention and Observational Studies.

J Am Med Dir Assoc 2020 10;21(10):1415-1422.e6

Unità Locale Socio Sanitaria 3 "Serenissima", Primary care Department, Venice, Italy; Geriatric Unit, Department of Internal Medicine and Geriatrics, University of Palermo, Palermo, Italy. Electronic address:

Objectives: The aim of this umbrella review was to determine the effect of physical activity/exercise on improving cognitive and noncognitive outcomes in people with MCI (mild cognitive impairment) and dementia.

Design: Umbrella review of systematic reviews (SR), with or without meta-analyses (MAs), of randomized controlled trials (RCTs) and observational studies.

Settings And Participants: People with MCI or dementia, confirmed through validated assessment measures. Any form of physical activity/exercise was included. As controls, we included participants not following any prespecified physical activity/exercise intervention or following the same standard protocol with the intervention group.

Methods: The protocol was registered in PROSPERO (CDR 164197). Major databases were searched until December 31, 2019. The certainty of evidence of statistically significant outcomes was evaluated using the Grading of Recommendations Assessment, Development and Evaluation approach. SRs' findings, without a formal MA, were reported descriptively.

Results: Among 1160 articles initially evaluated, 27 SRs (all of RCTs, 9 without MA) for a total of 28,205 participants with MCI/dementia were included. In patients with MCI, mind-body intervention (standardized mean difference [SMD] = 0.36; 95% confidence intervals [CI] 0.20-0.52; low certainty) and mixed physical activity interventions (SMD = 0.30; 95% CI 0.11-0.49; moderate certainty) had a small effect on global cognition, whereas resistance training (SMD = 0.80; 95% CI 0.29-1.31; very low certainty) had a large effect on global cognition. In people affected by dementia, physical activity/exercise was effective in improving global cognition in Alzheimer disease (SMD = 1.10; 95% CI 0.65-1.64; very low certainty) and in all types of dementia (SMD = 0.48; 95% CI 0.22-0.74; low certainty). Finally, physical activity/exercise improved noncognitive outcomes in people with dementia including falls, and neuropsychiatric symptoms.

Conclusions And Implications: Supported by very low-to-moderate certainty of evidence, physical activity/exercise has a positive effect on several cognitive and noncognitive outcomes in people with MCI and dementia, but RCTs, with low risk of bias/confounding, are still needed to confirm these relationships.
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http://dx.doi.org/10.1016/j.jamda.2020.08.031DOI Listing
October 2020

Association between number of medications and mortality in geriatric inpatients: a Danish nationwide register-based cohort study.

Eur Geriatr Med 2020 12 9;11(6):1063-1071. Epub 2020 Sep 9.

Geriatric Research Unit, Department of Clinical Research, University of Southern Denmark, Odense, Denmark.

Purpose: To explore the association between the number of medications and mortality in geriatric inpatients taking activities of daily living and comorbidities into account.

Methods: A nationwide population-based cohort study was performed including all patients aged ≥ 65 years admitted to geriatric departments in Denmark during 2005-2014. The outcome of interest was mortality. Activities of daily living using Barthel Index (BI) were measured at admission. National health registers were used to link data on an individual level extracting data on medications, and hospital diseases. Patients were followed to the end of study (31/12/2015), death, or emigration, which ever occurred first. Kaplan-Meier survival curves were used to estimate crude survival proportions. Univariable and multivariable analyses were performed using Cox regression. The multivariable analysis were adjusted for age, marital status, period of hospital admission, BMI, and BI (model 1), and additionally either number of diseases (model 2) or Charlson comorbidity index (model 3).

Results: We included 74,603 patients (62.8% women), with a median age of 83 (interquartile range [IQR] 77-88) years. Patients used a median of 6 (IQR 4-9) medications. Increasing number of medications was associated with increased overall, 30-day, and 1-year mortality in all three multivariable models for both men and women. For each extra medication, the mortality increased by 3% in women and 4% in men in the fully adjusted model.

Conclusion: Increasing number of medications was associated with mortality in this nationwide cohort of geriatric inpatients. Our findings highlight the importance of polypharmacy in older patients with comorbidities.
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http://dx.doi.org/10.1007/s41999-020-00390-3DOI Listing
December 2020
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