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Các nhóm thuốc hạ huyết áp mới hơn, chẳng hạn như các chất đối kháng thụ thể angiotensin II, có thể mang lại lợi ích cho bệnh nhân ngoài khả năng hạ huyết áp của chúng. Người ta đã công nhận rằng tăng huyết áp mạn tính góp phần vào sự phát triển của bệnh lý mạch máu não và tim mạch, và một số nghiên cứu đã chỉ ra mối liên hệ giữa tăng huyết áp và suy giảm chức năng nhận thức, đặc biệt ở những bệnh nhân không sử dụng thuốc hạ huyết áp. Trong một thử nghiệm lâm sàng ban đầu, chất đối kháng thụ thể angiotensin II losartan đã được chứng minh là cải thiện chức năng nhận thức ở những bệnh nhân bị tăng huyết áp, bao gồm cả những người lớn tuổi (lên đến 73 tuổi). Hiệu ứng này không thể được giải thích chỉ bằng việc giảm huyết áp và có thể liên quan đến các tương tác với các tác động sinh học khác nhau của hệ thống renin-angiotensin. Cải thiện hoặc duy trì chức năng nhận thức ở những bệnh nhân bị tăng huyết áp có thể mang lại lợi ích kinh tế ngoài những gì mong đợi từ việc kiểm soát huyết áp, và sẽ mang lại những lợi ích đáng kể về chất lượng cuộc sống cho dân số già.

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines have been promulgated to improve the management of chronic obstructive pulmonary disorder (COPD). To evaluate the extent to which the current therapeutic approach to COPD conforms to GOLD guidelines. This was a multicentre observational study of elderly COPD patients enrolled for acute care in general medicine or geriatric wards in tertiary hospitals in Italy in April 2002. Our series consisted of 471 patients >64 years of age consecutively admitted for acute exacerbations of COPD to wards participating in the study. Data describing drugs used prior to exacerbation and prescribed at discharge were collected using a standardised protocol. Changes in prescription at discharge were then compared with home therapy. Demographic variables and indices of COPD severity and co-morbidity were tested as potential correlates for the main outcome measure ‘variant prescription’, i.e. prescription of a drug considered as a third-line treatment (e.g. methylxanthines) or not recommended (e.g. mucolytics) by GOLD guidelines. The correlation was assessed first by univariate analysis and then by logistic regression analysis. At discharge, prescription of short-acting β2-adrenoceptor agonists had decreased from 26.3% to 14.0%. Conversely, increases in prescription of long-acting β2-adrenoceptor agonists (from 43.1% to 68.4%), inhaled corticosteroids (50.7% to 69.6%) and anticholinergics (17.2% to 22.3%) were seen. The rate of use of methylxanthines was 49.7% before admission and 44.8% at discharge, with previous use being the main correlate of discharge prescription for this class of drugs (odds ratio [OR] = 4.35; 95% CI 2.88, 6.54). The rate of use of mucolytics was 26.3% before admission and 26.8% at discharge, with use of mucolytics prior to admission being the only correlate of discharge prescription (OR = 4.10; 95% CI 2.47, 6.82). Hospitalisation resulted in increased adherence to GOLD guidelines in patients with COPD, but the rate of use of anticholinergics was distinctly low and that of methylxanthines and mucolytics surprisingly high. A carry-over effect (i.e. of therapy prescribed by general practitioners on that prescribed by hospital-based physicians) likely accounts for most of the ‘variant prescriptions’ seen at discharge from the acute care hospital.

Bacteraemia is a common disorder in the elderly, and its prevalence and incidence increase with age. It carries a mortality rate of 20 to 40%. The signs and symptoms of bacteraemia are often blunted or nonspecific in the elderly, and the index of suspicion should therefore be high. Comparing underlying disorders of bacteraemia between older and younger patients, the percentage of past cerebrovascular accidents, dementia and decubitus ulcer increases sharply with age, while the percentage of neutropenia is lower. Elderly patients have a predilection for anaerobic bloodstream infections, and for multiresistant bacteria, although age is not an independent risk factor for resistance. Bacterial endocarditis in the old is caused mainly by gut bacteria. Appropriate empirical antibiotic treatment reduces mortality, regardless of age. To target antibiotic treatment, the physician should consider the patient’s salient features, and the overall susceptibility of the micro-organisms in the local ecosystem. The most important supportive measure for treatment of sepsis or septic shock is fluid repletion. No non-antibiotic drug has been shown to be effective in sepsis.

Polypharmacy in multimorbid older patients with atrial fibrillation (AF) is a risk factor for potentially inappropriate prescribing (PIP). We aimed to systematically assess the evidence on the prevalence of PIP and its impact on adverse health outcomes in this patient group. A systematic search of the published peer-reviewed literature describing the prevalence of PIP and/or its association with adverse health outcomes in multimorbid (AF plus one comorbidity) and polymedicated (≥ 2 drugs) adults ≥ 65 years was done up to March 2023. A meta-analysis of the prevalence of PIP of (direct) oral anticoagulants ((D)OACs) was conducted using a random-effects model. Leave-one-out analysis was performed with R (version 4.2.2) and RStudio (version 2022.12.0+353). Of the 12 studies included, only one reported on the prevalence of overall PIP (65%). The meta-analysis of 10 studies assessing PIP of (D)OACs produced a pooled prevalence [95% confidence interval (CI)] of 35% [30–40%], with significant heterogeneity between the included studies (I2 95%). No statistically significant association was reported in three studies between PIP of (D)OACs, cardiovascular (CV) and all-cause mortality, hospital readmission, CV hospitalisation and stroke. Reported associations between PIP and major bleeding differed, with one study demonstrating a significant association (odds ratio 2.17; 95% CI 1.14–4.12) and the other study not showing such association. This systematic review highlights the scarce evidence regarding the prevalence of PIP and its association with adverse health outcomes in multimorbid older adults with AF. Large, prospective and better-designed studies are needed.

Bullous pemphigoid (BP) is the most common autoimmune blistering skin disease. Until recently the condition was treated with oral corticosteroids. However, high-dose corticosteroids are poorly tolerated in the elderly and their use has probably contributed to the high mortality rates observed in several cohorts. Accordingly, considerable effort has been directed at identifying corticosteroid-sparing agents, such as immunosuppressant drugs, plasma exchange techniques, intravenous immunoglobulins and tetracycline, that can be used in this clinical setting. Many of these options have appeared to be useful in open series, but they have been found to be ineffective or only marginally effective when tested in randomised, controlled trials. An important breakthrough occurred with the demonstration in a large, randomised trial that a ‘super-potent’ topical corticosteroid (clobetasol propionate) was not only associated with a significant decrease in severe complications and mortality of BP patients, but was also more effective than oral prednisone. New strategies for BP should include topical clobetasol propionate as first-line therapy in the elderly and consider adjuvant therapy only in the very rare cases that are either resistant or intolerant to this treatment.

Chronic obstructive pulmonary disease (COPD) is a debilitating disease with rising worldwide prevalence. Exacerbations of COPD cause significant morbidity and become more common with advancing age. Healthcare providers caring for elderly patients should therefore be familiar with effective treatments for exacerbations of COPD. An extensive body of literature has identified several effective drug therapies for exacerbations. These drugs include inhaled bronchodilators, systemic corticosteroids and antibacterials. The two main classes of inhaled bronchodilators are β-adrenoceptor agonists and anticholinergics. These drugs optimise lung function during exacerbations, with neither class demonstrating clear superiority over the other. Systemic corticosteroids are effective when used either for inpatient or outpatient treatment of exacerbations. They hasten recovery from exacerbations and reduce relapse rates. Antibacterials decrease morbidity from exacerbations and may decrease mortality in the more severe exacerbations. Other effective therapies for the treatment of acute exacerbations of COPD include oxygen and non-invasive ventilation. Oxygen can be safely administered in acute exacerbations associated with hypoxaemia, with titration of oxygen delivery to a goal oxygen saturation of 90%. Non-invasive ventilation reduces the morbidity and mortality associated with acute exacerbations complicated by hypercapnic respiratory failure. Strategies to prevent COPD exacerbations include smoking cessation, long-acting inhaled β-adrenoceptor agonists, inhaled long-acting anticholinergics, inhaled corticosteroids and vaccination. Mucolytic agents, pulmonary rehabilitation, and case management programmes may also reduce exacerbation risk, but the current evidence supporting these interventions is weaker.

Although an equimolar mix of nitrous oxide-oxygen (N2O/O2) [Kalinox®] is widely used as an analgesic, there have been few specific studies of this product in the elderly. In this article, we investigate the tolerability of this equimolar mix in very elderly patients undergoing painful procedures. This was a prospective, observational study of patients hospitalised in the geriatric short-stay unit of a teaching hospital between July 2001 and September 2003. All patients aged ≥80 years who were scheduled for invasive care procedures were eligible for inclusion. Sixty-two patients were recruited and underwent a total of 68 procedures. The procedures were divided into four classes based on the degree of pain they were expected to cause and their duration. Patients received the equimolar N2O/O2 mix (Kalinox®) for 5 minutes before the beginning of the procedure and throughout its duration. The inhaled treatment was administered via a high-concentration mask. Assessments were carried out during the inhalation and over the 15 minute period following inhalation. The primary endpoint of the study was tolerability of the equimolar N2O/O2 mix, and all adverse events were recorded. Secondary endpoints were the efficacy of the product (assessed on a verbal rating scale and/or the Doloplus scale), its ease of use and its acceptability to patients and staff. Fourteen patients (22.6%) each reported at least one adverse event: impaired hearing (n = 1), altered perception of the environment (n = 8), anxiety (n = 1), headache (n = 3) and drowsiness at the end of the procedure (n = 2). All these disorders subsided rapidly after treatment was completed. This study shows the favourable tolerability of the equimolar N2O/O2 mix in very elderly subjects, which makes this product a valuable tool for the management of acute pain in this age group.