Annette Eidam

Zusammenfassung Beobachtungsstudien an großen Kohorten schienen in der Vergangenheit aufzuzeigen, dass eine höhere Proteinzufuhr generell mit einer Verlangsamung des altersassoziierten Abbaus von Muskelmasse und Muskelkraft assoziiert war. Damit lag die Schlussfolgerung nahe, dass diese einen Beitrag zum Funktionserhalt und zur Prävention der Sarkopenie leisten kann. Die Deutsche Gesellschaft für Ernährung entschloss sich daher, die Empfehlung für die tägliche Proteinzufuhr bei über 65-Jährigen von 0,8 auf 1,0 g/kgKG (Schätzwert) anzuheben. Die aktuelle Studienlage deutet jedoch darauf hin, dass bei gesunden älteren Erwachsenen kein positiver Effekt auf Muskelmasse oder Kraftparameter durch eine höhere Proteinzufuhr erzielt werden kann. Eine diesbezüglich positive Wirkung auf die Muskelgesundheit lässt sich jedoch bei Patienten mit bereits vorhandener Sarkopenie für die Kombination aus einer höheren Proteinzufuhr und einem Krafttraining annehmen, während die Evidenz für eine isolierte Erhöhung der Proteinzufuhr in diesem Kollektiv weniger überzeugend ist. Aktuelle Forschungsfragen betreffen gegenwärtig die Wirkung unterschiedlicher Proteinarten auf Muskelmasse und Muskelkraft sowie die Relevanz einer veganen Ernährung mit Hinblick auf ein gesundes Altern (Healthy Aging).

Zusammenfassung Ältere Patienten mit Frailty zeigen eine gesteigerte Vulnerabilität für negative Gesundheitsereignisse, die unter anderem als Folge von unerwünschten Arzneimittelwirkungen eintreten. Angesichts der komplexen klinischen Bedarfe älterer Patienten mit Frailty sollte in dieser Population ein fokussiertes Medikationsmanagement erfolgen. Als Orientierungspunkt können dabei die Konsensusprinzipien für die klinische Praxis des Optimizing Geriatric Pharmacotherapy through Pharmacoepidemiology Network herangezogen werden. Diese betonen die Bedeutung eines konsolidierten Medikationsplans, einer Berücksichtigung der individuellen Fähigkeiten zum Medikamentenmanagement („medication management capacity“) und eines angemessenen Verschreibungsverhaltens. Zahlreiche Arzneistoffe können verschiedene geriatrische Syndrome nachteilig beeinflussen. Die Evidenzlage zur Arzneimitteltherapie bei Frailty ist bislang limitiert. Seit wenigen Jahren sind verstärkte Bemühungen zu verzeichnen, ältere Patienten mit Frailty retrospektiv unter den Teilnehmern randomisierter kontrollierter Studien zu identifizieren. Zur Identifikation wird unter anderem der Frailty-Index nach Rockwood herangezogen. Eine zusätzliche Möglichkeit der Evidenzgewinnung zur Pharmakotherapie bei Frailty stellt die Auswertung von Routineversorgungsdaten dar.

Background: Healthcare providers should balance the potential risks and benefits of chronic diuretic use, particularly in older adults, as with age, diuretic benefits may decline and risks increase. A comprehensive synthesis and critical evaluation of the available evidence on chronic diuretic treatment effects is currently lacking. Methods: We conducted an umbrella review of systematic reviews and meta-analyses published since 2018 on health outcomes associated with diuretic use in randomized-controlled trials (RCTs). We conducted random-effects meta-analysis for pooled effect estimates and narratively summarized data that could not be pooled. Results: We included 741 effect estimations from 117 systematic reviews (SRs) on 1566 RCTs in individuals aged 62 ± 6 years. Of our 33 meta-analyses, 11 provided convincing, high-quality evidence: finerenone reduced the risk of cardiovascular (CV) mortality and end-stage kidney disease in individuals with chronic kidney disease (CKD) and/or type 2 diabetes (T2D). Torasemide reduced the risk of heart failure-related hospitalization (HFH) more than furosemide in individuals with HF. Thiazides reduced CV events in individuals with hypertension. Mineralocorticoid receptor antagonists (MRAs) reduced HFH, but also increased hyperkalemia risk in individuals with HF. MRAs also reduced the risk of atrial fibrillation in those with HF or CVD, and reduced HFH, major adverse cardiovascular events (MACEs), > 40% eGFR decrease, and composite kidney outcomes in individuals with CKD and/or T2D. Lower quality evidence suggests that in older (≥ 65 years), but not in younger adults, diuretics may reduce CV mortality, but also increase adverse event (AE) risk. Conclusions: Our umbrella review offers a comprehensive and up-to-date evaluation of the benefits and harms of diuretics. However, further research is needed to establish their efficacy and safety in populations commonly seen in clinical practice, especially older adults living with multimorbidity and frailty. Graphical

Zusammenfassung Hintergrund Das Vorliegen einer Frailty erhöht beim älteren Patienten das Risiko für ungünstige Gesundheitsereignisse und den Verlust der Selbstständigkeit. Maßnahmen zur Prävention dieses geriatrischen Syndroms sollten in die allgemeine Gesundheitsversorgung integriert werden. Fragestellung Welche Interventionen versprechen Wirksamkeit in der Prävention einer Frailty, und wie lässt sich eine erfolgreiche Implementation präventiver Strategien gestalten? Methode Narrative Übersichtsarbeit. Ergebnisse Frailty ist als Konzept multidimensional, sodass sich Ansatzpunkte für eine Prävention von Frailty auf unterschiedlichen Ebenen (z. B. Ebenen der körperlichen Aktivität und Ernährung, psychosoziale Ebene) finden. Aus epidemiologischen Analysen konnten Faktoren identifiziert werden, die das Risiko für die Ausbildung einer Frailty erhöhen oder verringern. Die Evidenz aus randomisierten kontrollierten Studien, die die Wirksamkeit spezifischer Interventionen in der Prävention einer Frailty untersucht haben, ist zum gegenwärtigen Zeitpunkt begrenzt. Ausgehend von den derzeit vorliegenden Daten scheinen Interventionen, die auf körperlichem Training basieren, in der Prävention von Frailty wirksam zu sein. Der Frailty-Status des älteren Patienten wird in Deutschland bislang nicht routinemäßig in der Primärversorgung erfasst, was die Identifikation der Risikogruppe (Patienten mit Pre-Frailty) und zielgerichtete Präventionsmaßnahmen erschwert. Einen Ansatz, um Frailty vorzubeugen und „Healthy Ageing“ innerhalb der Bevölkerung zu fördern, bietet das Konzept Integrated Care for Older People (ICOPE) der Weltgesundheitsorganisation. Schlussfolgerungen Die Prävention einer Frailty ist möglich und sinnvoll. Bislang fehlt eine flächendeckende Implementation zielgerichteter Präventionsstrategien.

Purpose: Frailty in older adults is associated with multiple adverse health outcomes, while evidence on its successful prevention has been scarce. Therefore, we analyzed the effectiveness of different interventions for the prevention of frailty onset. Methods: In this systematic review, eight databases were searched for randomized controlled trials of interventions in non-frail (i.e., robust or pre-frail) adults aged ≥ 60 years that assessed frailty incidence at follow-up. Additive component network meta-analysis (CNMA) was conducted to isolate the effect of different intervention types on the main outcome of frailty incidence, reporting relative risk (RR) with 95% confidence intervals (CI). The effect on gait speed was analyzed as an additional outcome using a classic network meta-analysis and the standardized mean difference (SMD) with 95% CI. Results: We screened 24,263 records and identified 11 eligible trials. Nine trials (842 participants, all categorized according to the physical phenotype) in pre-frail (seven RCTs) and robust/pre-frail (two RCTs) older adults were included in the CNMA. Physical exercise significantly reduced frailty incidence at follow-up (RR 0.26, 95% CI 0.08; 0.83), while this was not found for nutritional interventions (RR 1.16, 95% CI 0.33; 4.10). Interventions based on physical exercise also improved gait speed (SMD 1.55, 95% CI 1.16; 1.95). In addition, 22 eligible trial protocols without published results were identified. Conclusion: Interventions based on physical exercise appear to be effective in preventing the onset of frailty in older adults. Although the available data are still limited, results from ongoing trials may add to the body of evidence in the foreseeable future.

Inappropriate polypharmacy is highly prevalent among older adults and presents a significant healthcare concern. Conducting medication reviews and implementing deprescribing strategies in multimorbid older adults with polypharmacy are an inherently complex and challenging task. Recognizing this, the Special Interest Group on Pharmacology of the European Geriatric Medicine Society has compiled evidence on medication review and deprescribing in older adults and has formulated recommendations to enhance appropriate prescribing practices. The current evidence supports the need for a comprehensive and widespread transformation in education, guidelines, research, advocacy, and policy to improve the management of polypharmacy in older individuals. Furthermore, incorporating deprescribing as a routine aspect of care for the ageing population is crucial. We emphasize the importance of involving geriatricians and experts in geriatric pharmacology in driving, and actively participating in this transformative process. By doing so, we can work towards achieving optimal medication use and enhancing the well-being of older adults in the generations to come.

Background Frailty makes older adults vulnerable to adverse health outcomes and can modify pharmacokinetics and drug exposure. Objective We aimed to explore the relationship between different frailty assessments and trough plasma concentrations of direct oral anticoagulants in older patients. Methods The frailty status of adults aged ≥ 70 years receiving regular direct oral anticoagulant medication was assessed by four different instruments: Fried physical phenotype, Rockwood frailty index, Short Physical Performance Battery, and FRAIL scale. The two performance measures “slow gait speed” and “weak grip strength” were used to build a separate score depending on the number of positive criteria (none, one, two). For each participant, a single steady-state direct oral anticoagulant trough plasma concentration was collected, dose-normalized, and its relationship to the various frailty assessments analyzed. Results Forty-two participants completed the study, with most using apixaban (n = 22). Dose-normalized apixaban trough concentrations were 2.48-fold higher in frail participants (Fried phenotype) than in robust participants (p = 0.009) and correlated positively with Fried physical phenotype (r_s = 0.535, p = 0.010) and negatively with Short Physical Performance Battery (r_s = − 0.434, p = 0.044). Compared with participants who met none of the criteria “slow gait speed” and “weak grip strength”, apixaban trough concentrations were approximately 1.9-fold higher in participants who were positive for one (p = 0.018) or two (p = 0.013) of these measures. Conclusions In this exploratory study, higher levels of frailty on performance-based frailty assessments were associated with higher apixaban exposure in older adults. Clinical Trial Registration German Clinical Trials Register DRKS00016741; registered 20 February, 2019.

Purpose: Medical decision-making in older adults with multiple chronic conditions and polypharmacy should include the individual patient’s treatment preferences. We developed and pilot-tested an electronic instrument (PolyPref) to elicit patient preferences in geriatric polypharmacy. Patients and Methods: PolyPref follows a two-stage direct approach to preference assessment. Stage 1 generates an individual preselection of relevant health outcomes and medication regimen characteristics, followed by stage 2, in which their importance is assessed using the Q-sort methodology. The feasibility of the instrument was tested in adults aged ≥ 70 years with ≥ 2 chronic conditions and regular intake of ≥ 5 medicines. After the assessment with PolyPref, the patients rated the tool with regard to its comprehensibility and usability and assessed the accuracy of the personal result. Evaluators rated the patients’ understanding of the task. Results: Eighteen short-term health outcomes, 3 long-term health outcomes, and 8 medication regimen characteristics were included in the instrument. The final population for the pilot study comprised 15 inpatients at a clinic for geriatric rehabilitation with a mean age of 80.6 (± 6.0) years, a median score of 28 (range 25– 30) points on the Mini-Mental State Examination, and a mean of 11.6 (± 3.6) regularly taken medicines. Feedback by the patients and the evaluators revealed ratings in favor of understanding and comprehensibility of 86.7% to 100%. The majority of the patients stated that their final result summarized the most important aspects of their pharmacotherapy (93.3%) and that its ranking order reflected their personal opinion (100%). Preference assessment took an average of 35 (± 8.5) min, with the instrument being handled by the evaluator in 14 of the 15 participants. Conclusion: Preference assessment with PolyPref was feasible in older adults with multiple chronic conditions and polypharmacy, offering a new strategy for the standardized evaluation of patient priorities in geriatric pharmacotherapy.