Geriatrics update 2015: Vaccination, frailty, chronic disease guidelines, and cognition
ABSTRACTThis paper discusses recent developments and recommendations for elderly patients concerning immunizations, heart failure, lipid therapy, blood pressure control, and dementia.
KEY POINTS
- Vaccination costs will increase—with unclear added value—with new guidelines for influenza and pneumococcal vaccines.
- Multiple simultaneous interventions for heart failure have additive value. These are education, a beta-blocker, an angiotensin-converting enzyme inhibitor, and, in some, an aldosterone antagonist, anticoagulation for atrial fibrillation, and an implantable cardioverter-defibrillator or cardiac resynchronization therapy.
- Statin therapy should be intensified with an eye to goals of care and tolerability rather than a specific lipid goal.
- Exercise improves physical and mental health in all, including the elderly.
- Dementia still has no magic bullet. Selective serotonin reuptake inhibitors might help behavior issues, and vitamin E might bring modest cognitive improvement but with possible risk.
HEART FAILURE
Eplerenone’s new role in mild heart failure
Aldosterone antagonists have been recommended for moderate to severe heart failure (New York Heart Association [NYHA] classes III and IV) for some time. The 2013 American College of Cardiology/American Heart Association (ACC/AHA) guidelines also recommend them for mild heart failure (NYHA II).4
The EMPHASIS trial5 (Eplerenone in Patients With Systolic Heart Failure and Mild Symptoms) randomized 2,737 patients, median age 69, with NYHA class II heart failure and an ejection fraction of no more than 35% to receive the aldosterone antagonist eplerenone (up to 50 mg daily) or placebo, in addition to recommended therapy. The trial was stopped early, after a median follow-up of 21 months, when the treatment group was found to have a significantly lower risk of cardiovascular death or hospitalization for heart failure or for any cause.
Of note: hyperkalemia occurred in 11.8% of the eplerenone group vs 7.2% in the placebo group (P < .001). The high frequency of hyperkalemia in the placebo group may have been due to concomitant use of angiotensin-converting enzyme (ACE) inhibitors.
Sodium restriction reasonable
Although sodium restriction has been standard practice in heart failure for decades, restricting sodium in the elderly was given only a IIa (“reasonable”) classification, based on level C (very limited) evidence.4
Strong evidence exists that middle-aged and young older adults with heart failure (with preserved or reduced ejection fraction) should reduce their sodium intake by about 1 g per day or aim for a mean 24-hour urinary sodium excretion of about 2.3 g per day. However, little evidence exists to support a specific long-term target intake, and no evidence exists for “old-old” patients (loosely defined as older than 75 or 80).
Caution with digoxin
Use of digoxin has been recommended in patients with heart failure with reduced ejection fraction to reduce hospitalizations,4 but more recent publications have raised questions regarding its safety and efficacy.
Freeman et al,6 in a prospective study, followed 2,891 patients with newly diagnosed systolic heart failure over 2.5 years, of whom 529 were prescribed digoxin. The digoxin group had a higher rate of death (14.2 vs 11.2 per 100 patient-years) and heart failure-related hospitalization (28.2 vs 24.4 per 100 person-years).
The study was unable to determine if the digoxin level influenced the results, since about 30% of patients had no digoxin level drawn, and an additional 27% had only one level drawn during the study. For those with measured blood levels, the mean digoxin level for men was 0.83 ng/mL and 1.12 ng/mL for women. Risks and benefits of this medication should be weighed carefully.
Simultaneous interventions beneficial
The following evidence-based interventions are recommended for patients with heart failure with reduced ejection fraction:
- Heart failure education
- A beta-blocker
- An ACE inhibitor
- An aldosterone antagonist for NYHA class II–IV symptoms
- Anticoagulation for atrial fibrillation in patients with added risks (eg, hypertension, diabetes, prior transient ischemic attack or cerebrovascular accident, age at least 75)
- An implantable cardioverter-defibrillator and cardiac resynchronization therapy for select patients with symptoms, increased QRS duration, and left bundle branch block.
Fonarow et al7 studied these interventions in an analysis of a prospective study of outpatients with diagnosed heart failure or myocardial infarction and reduced left ventricular ejection fraction. Their nested case-control study compared 1,376 patients, mean age 72, who had died within 24 months and 2,752 propensity-matched controls who survived to 24 months. The survival rate was 37% higher with two simultaneous interventions than with one, and 70% higher with four simultaneous interventions than with one. Benefits plateaued with four to five interventions.
LIPID-LOWERING THERAPY FOR SENIORS
The 2013 ACC/AHA cholesterol guideline8 included new recommendations specifically relevant to the elderly. It advocates using a new cardiovascular disease risk calculator that provides an estimate of 10-year risk of atherosclerotic cardiovascular disease (ASCVD), based on data from multiple community-based populations and applicable to African American and non-Hispanic white men and women ages 40 through 79. Primary prevention with a statin is encouraged for those with a 10-year risk of 7.5% or higher. The tool generated controversy from the moment it was announced and may overestimate ASCVD risk by 67% in women and 86% in men.9
Emphasis on tolerability
The guideline focuses on statins as the main treatment and de-emphasizes the adjunctive use of other drugs to further lower lipids such as niacin, ezetimibe, and fenofibrate.
Statin tolerability is now stressed rather than specific lipid level targets. The guideline recommends reassessing statin choice and intensity according to pain, tenderness, stiffness, cramping, weakness, and fatigue (class IIa recommendation [“reasonable”], level of evidence B [“limited”]). Also recommended is reassessment of statin choice and intensity for patients older than 75 or for those taking multiple medications, drugs that alter metabolism, and conditions requiring complex medications (class IIa, level of evidence C [“very limited”]). For patients with confusion, statin and nonstatin causes should be considered as the source of the problem (class IIb [“consider”], level of evidence C).
Initiating high-intensity statin therapy is not recommended after age 75. However, continuing such treatment is reasonable for patients already receiving and tolerating the therapy for an appropriate indication. Initiation of moderate-intensity statin therapy in this age group is recommended for those with either clinical atherosclerotic cardiovascular disease or a low-density lipoprotein cholesterol (LDL-C) level of at least 190 mg/dL.
No specific guidance is provided for patients older than age 75 without ASCVD, with LDL-C less than 190 mg/dL, or with diabetes. In these groups, statin therapy may be initiated, continued, or intensified (class IIb, level of evidence C).
HYPERTENSION: LESS AGGRESSIVE GOALS FOR ELDERLY
The eighth Joint National Committee (JNC 8)10 made nine recommendations for managing high blood pressure, only one of which specifically addresses people 60 and older.
Drug therapy should be initiated if the blood pressure is 150/90 mm Hg or higher, and the blood pressure should be treated to less than that level (grade A recommendation, ie, strong). If treated systolic blood pressure is less than 140 mm Hg without adverse effects, it should be sustained (grade E recommendation, ie, based on expert opinion).
Tension between guidelines
The higher threshold for hypertension treatment and the lower threshold for statin therapy create tension between guidelines, and between guidelines and epidemiologic data.
For example, in a 67-year-old woman without diabetes and with a favorable lipid profile (eg, total cholesterol 130 mg/dL, high-density lipoprotein cholesterol 55 mg/dL), the ACC/AHA ASCVD risk calculator predicts a 10-year risk of less than 7.5% if her systolic blood pressure is 147 mm Hg. If the patient’s blood pressure were 148 or 149 mm Hg and all the other variables were the same, the JNC 8 would not recommend treatment with antihypertensive medication, but the ACC/AHA guidelines would recommend preventive statin therapy.
Another example is the relationship between heart failure and antihypertensive drugs. Multiple studies11,12 demonstrate a reduction in heart failure incidence with hypertension treatment. A 70-year-old man whose systolic blood pressure is 140 mm Hg has about a 15% lifetime risk of heart failure. If his systolic pressure were 160 mm Hg, his lifetime heart failure risk would be more than 50%.13 If his systolic pressure were 149, his lifetime risk of heart failure would be between 15% and 50%, but the JNC 8 criteria do not recommend antihypertensive therapy.
EXERCISE SLOWS PROGRESSION TO FRAILTY
In the absence of a gold standard, frailty has been operationally defined as meeting three out of five phenotypic criteria: diminished grip strength, low energy, slow gait, low physical activity, and unintentional weight loss. A “prefrail” stage, in which one or two criteria are present, identifies a vulnerable subset at high risk of progression to frailty.
About 42% of older adults in the community are considered vulnerable, or prefrail, and about 11% are frail.14 Interventions at the prefrail stage may prevent progression to frailty, but it is rare, without intervention, for a person to re-achieve the stronger stage once diagnosed with frailty.
Pahor et al15 randomized 1,635 sedentary adults ages 70 to 89 who met the criteria of prefrailty to either a moderate-intensity exercise program (consisting of aerobic, resistance, and flexibility exercises for 150 minutes per week, performed in a center and at home) or to a health education program with workshops on topics relevant to older adults and upper-extremity stretching exercises. Adherence to the exercise program was verified by questionnaire and an accelerometer device. Participants were assessed every 6 months for an average of 2.6 years.
The primary outcome measure was the development of major mobility disability as defined by the loss of ability to walk 400 m without assistance (a cane was acceptable, but not a walker). The primary outcome occurred in 30.1% of those in the exercise group and 35.5% of the health education group (hazard ratio 0.82, P = .03). Those in the exercise group also had one third fewer falls. No differences were found in death rates. The number needed to treat was about 19 to prevent one person from developing major disability. Those most likely to benefit were those who walked slowly at baseline (< 1.8 mph), were more mobility-impaired, and were more cognitively healthy.
