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Lege Artis Medicinae

MARCH 10, 2020

[Primary care strategy of antihypertensive treatment of very elderly and frail patients]

TORZSA Péter, KALABAY László, CSATLÓS Dalma, HARGITTAY Csenge, MÁRKUS Bernadett, MOHOS András, SZIGETI Mátyás, FERENCI Tamás, MARJOLEIN Verschoor, ROZSNYAI Zsofia, JACOBIJN Gussekloo, ROSALINDE K. E. Poortvliet, SVEN Streit

[BACKGROUND - When treating very el­der­ly and frail hypertensive patients, there have to be taken in account the general health condition and frailty of patients, the present cardiovascular diseases (CVD) and values of the systolic blood pressure (SBP). Goals - In a clinical study performed in 29 countries, we aimed to analyse differences in practical antihypertensive therapy of family doctors among patients older than 80 years; further we sought to answer how much was influenced their therapeutic choice by frailty of the old age. The other goal of our study was to compare Hungarian versus international outcomes. Methodology - As part of an online survey, family practitioners had to decide about necessity of starting antihypertensive treatment among very elderly patients according to different patterns of frailty, SBP and CVD. The ratio of specific cases with positive treatment decision of family practitioners was compared in all 29 countries. We used a logistic mixed model analysis to multivariately model the role of frailty. Results - 2543 family practitioners participated in the cross-national study; 52% were female; 51% practised in urban environment. In 61% of practices, there was the ratio higher than 10% of very elderly patients. Hungary participated with 247 family practitioners in the study; 52.3% were female; 63.1% practised in urban environment. In 48.8% of practices the ratio of very elderly patients was higher than 10%. In 24 out of the 29 countries (83%), frailty was associated with GPs’ negative decision about starting treatment even after adjustment for SBP, CVD, and GP characteristics (odds ratio [OR 0.53]), 95% CI: 0.48-0.59; ORs per country 0.11-1.78). The lowest treatment ratio was in the Netherlands (34.2%; 95% CI: 32.0-36.5%) and the highest one in Ukraine (88.3%; 95% CI: 85.3-90.9%). In Hungary’s treatment ratio ranged 50-59%. This country ranked on the 27th place since Hungarian family practitioners chose rather to start antihypertensive treatment despite the frailty of the patient (OR=1.16; 95% CI: 0.85-1.59). Hungarian family practitioners started pharmacotherapy of elderly patients more frequently if they were males (OR= 1.45; 95% CI: 0.81-2.61), were working in their practice for less than 5 years (OR=2.41; 94% CI: 0.51-11.38), and if they had many patients aged over 80 years in their practice (OR=2.18; 95% CI: 0.70-6.80), however these differences were sta­­tistically not significant. Among Hun­ga­rian family practitioners starting therapy was significantly influen­ced by cardiovascular disease (OR=3.71; 95% CI: 2.64-5.23) and a SBP over 160 mmHg (OR=190.39; 95% CI: 106.83-339.28). Conclusions - In our study, there was significant difference between countries in starting antihypertensive treatment for very elderly patients. However, Hungary was among the countries where family practitioners preferred to treat their frail patients. The patients’ frailty did not have any impact on starting the therapy; rather cardiovascular disease and a SBP over 160 mmHg decided. It is an important message of the study that there is continuous need to educate family practitioners and trainees about the treatment of frail, elderly hypertensive patients.]

Hypertension and nephrology

DECEMBER 12, 2019

[Hypertension and brain function. Correlation of high blood pressure and demencia in aging. Hypertension in young-middle adults - demencia in elderly]

SZÉKÁCS Béla, KÉKES Ede

[The cerebral vascular damage caused by hypertension is manifested primarily in cognitive dysfunction, which is caused by hypoperfusion of brain tissue, ischemic, or bleeding stroke, or white matte injury. Hypertension may not only result in cerebral damage to the vascular background - dementia -, but may also contribute to the development and progression of classical gene-related Alzheimer’s disease. Blood pressure gradually increases in the elderly and in the very elderly, and the frequency of hypertension-mostly as isolated systolic hypertension - is 50% to 70%. High blood pressure predominately, or in full, means not only an increase in the circulatory resistance of the small children, but also, as part of the aging of the body, the rigidity (stiffness) of the arteries. At the same time, the incidence of dementia, along with age, rises sharply - up to 20% in those over 65 years of age, and over 40% in 80-90 years of age. The relationship between high blood pressure and dementia from the young age to the very old age may change as a function of current age. In the very old age of life, the varying influence of other pathological factors other than hypertension is becoming more and more important in the deterioration of both the vascular structure and the brain function. In this late stage of life, the very advanced rate of aging and nutritive blood flow often require higher perfusion pressure, and the not enough thought-out blood pressure reduction can be more damaging than a protective effect on brain condition or function. SPRINT MIND - the Intense Blood Pressure Reduction - hasn’t resolved the question, and we can legally assume that the 130-140 Hgmm SBP. Is the most favorable for dementia. The value of DBP 70 Hgmm is definitely unfavorable.]

Lege Artis Medicinae

NOVEMBER 15, 2019

[Hypertension in the elderly ]

BARNA István

[Elevated isolated systolic pressure is the most common and greatest cardiovascular risk factor with age. The prevalence of hypertension increases with age and ex­ceeds 60% over 70 years. Proper treatment of hypertension in the elderly, even in very old age (> 80 years), increases life expectancy and reduces the risk of cardiovascular events. For patients over 65 years of age, the target blood pressure range is between 130-139 / 70-80 mmHg if the patient tolerates the treatment. In elderly patients with poorer conditions, systolic blood pressure may be <150 mmHg. White-coat hypertension is common, nondipper ratio is increased, autonomic nervous system dysregulation is more common, and orthostatic decrease of blood pressure. The renal function is decreased or already impaired, often resulting in poorer therapeutic cooperation due to impaired cognitive function. The blood pressure lowering effect of targeted lifestyle changes may be the same as medication monotherapy, with the main disadvantage of decreasing adherence over time, for which a proper physician-patient relationship is essential. First-line agents for the treatment of elderly hypertension include angiotensin converting enzyme inhibitors (ACE inhibitors), angiotensin receptor blockers (ARBs), long-acting calcium channel blockers, and thiazide, thiazide-like diuretics. Beta-blockers should be used in the treatment of elderly hypertension if they have other indications (coronary heart disease, heart failure, arrhythmias). More than 70% of hypertensive patients should use combination therapy to achieve target blood pressure. Take advantage of fixed dose combination to improve compliance to optimize treatment. ]

Lege Artis Medicinae

SEPTEMBER 10, 2019

[The health economic ISSUES of geriatric care in Hungary]

NÉMETH Bertalan

[INTRODUCTION - In Hungary, the ageing of the population is a major challenge for the healthcare system (and for the social care). Due to the complexity of treatment of the elderly, geriatric care needs to have a special integrative approach, in order to function effectively. METHODS - We analysed the data that was made publicly available by the Hungarian Payer, together with domestic and international publications, to provide suggestions regarding geriatric care. RESULTS - Based on public data, the utilization of geriatric healthcare services is low, and major differences could be observed within different areas of the country. Within outpatient care, geriatric care shows a decreasing trend. DISCUSSION - It is complicated to navigate through the services provided by the Hungarian healthcare system, while international examples show that additional health gain can be realized with geriatric care. The role of geriatric care needs to be increased within the Hungarian healthcare system, together with addressing the shortage of experts, and clarification of the relations and coordination amongst macro-level systems, and different healthcare professions.]

Hypertension and nephrology

SEPTEMBER 10, 2019

[Hungarian Hypertension Registry. Different methods and effects of increasing physician-patient cooperation on target blood pressure]

SZEGEDI János, KÉKES Ede, KISS István

[The life expectancy, the mortality and the development of complications of hypertensive patients are fundamentally influenced by the treatment, the effectiveness of care and physician-patient cooperation, the achievement of target blood pressure. Based on the database of the Hungarian Hypertonia Registry, we present three examples of the effect of different solutions for physician-patient cooperation on increasing the blood pressure target. During the two years between 2005 and 2007, we used a complex, versatile method of increasing the patient’s adherence in treated hypertensive patients (17,114 males and 21,772 women), with information, education, home-blood pressure diary, and continuous, regular physician- patient communication (sms, green phone line, website). The target blood pressure was significantly increased from 38.8% to 43.9%, and the rate of growth was higher in women. The increase was also significant in the elderly (over 70 years). In the first quarter of 2011, we launched a wide-ranging education and patient support campaign for 28,018 hypertensive patients under the ‘Everywhere Good, Best Home!’ subprogram for promoting of home blood pressure measurement and its use in therapy. 81.3% of the patients had completed the diaries under ther observation period, the full completion of the diaries was 91.3%. At the end of the third month, the target blood pressure of 135/85 mmHg for HBPM increased from baseline 21.2% to 48.8%. Growth was significant (P <0.001). In the year 2015-2016 we started a one-year, multicentric, prospective, observational study, in which 7735 patients aged 18-64 years were included from the database of Hungarian Hypertension Registry. In the non-active group (3313 people), treated hypertensive patients were controlled according to the traditional care program so far, while the active group members (4422) participated in an intensive care program with telemedicine (smart phone application) and other helping opportunities. The control was done at the end of 3, 6, 9, and 12 months after the start. In the active group, blood pressure dier was done by smart phone and every month, in the non-active group, paper logging was done every 3 months. In the active group, the blood pressure dieries were filled with smart phone every month and in nonactive group the paper dieries only every 3 months. Patient adherence was high in both groups (around 70%) and in the active group was greater than in the nonactive group. Target blood pressure (<140/90 mmHg) in the active group increased from 53.8% to 73.4% and in the non-active group from 49.9% to 68.1%. Studies have shown that patient interaction is determined by good communication between the care team and the patient, success of home blood pressure monitoring. The communicative ability of the care team (physician-nurse pharmacist) greatly influences the achievement of the therapeutic target. Modern telecommunications is another useful option.]

Lege Artis Medicinae

MARCH 20, 2019

[Physiological-pathological muscle atrophy in elderly - interventions potencially inhibiting this progressive process ]

SZÉKÁCS Béla, MOLNÁR Andrea, BESENYEI Attila, MARTONY Zsuzsanna

[In old and very old age, one of the most prevalent signs of aged body’s decline is the progressive loss of muscle mass and function. First itself the physiological aging process can be dominant in the complex causative background but later it is usually intertwined with pathological mechanisms. The importance of muscle system is extremely high in the physiological regulation of various vital life processes The paper also points out the far-reaching consequences of sarcopenia syndrome that leads to general weakness, falls, traumas, acceleration of co-morbidities, rapidly declining self independence, ultimately frailty syndrome, and death. The initial body mass index has been recently replaced by a more adequate, more complex diagnostic approachment of sarcopenia that evaluates both muscle mass/strength and physical performance. Prevention or breaking the process of sarcopenia needs complex intervention which includes special fast protein rich diet with leucin and vitamin D combined with frequent physical exercise. ]

Hypertension and nephrology

FEBRUARY 20, 2019

[Statins for elderly people, in primary prevention?]

BAJNOK László

[In a recent, retrospective cohort study, statin usage in primary prevention was found being not beneficial for patients (i) without diabetes over 75 years of age, and (ii) with diabetes over 85 years of age (75-84 years total mortality of diabetics was also lower). These findings are in sharp contrast to the two outstanding, double-blind, placebo controlled, randomized, a primary prevention studies done with rosuvastatin. Of these, 50% reduction in LDL-C in JUPITER was associated with a 50% reduction in risk and 25% reduction in LDL-C in HOPE-3 with 25% reduction in risk. Furthermore, subgroup analyzes did not indicate lower efficacy for the elderly. The recommendation of the European Atherosclerosis Society for primary preventions of the elderlies recommending consideration of statin use in these cases (Class IIa) is particularly relevant, especially in the presence of other risk factors such as hypertension. In the primary prevention lipid treatment, we can see quite clearly till 75 years of age and hopefully, we will even further after learning about the results of STAREE, a study that is designed to elderly and in which 40 mg atorvastatin is applied.]

Lege Artis Medicinae

JANUARY 20, 2019

[Animal-assisted therapies for the treatment of elderly dementia ]

SOMOGYI Szilvia

[The therapeutic value of the relationship between humans and animals should be considered in the cases of patients suffering from dementia with the onset in old age. This paper provides an overview of the animal assisted interventions in dementia. Reviews emphasize the positive effects of pet-keeping on mental and physical quality of life. However, it can also have adverse effects unless the pet is selected with caution. Regular animal assisted therapies within institutional framework provide a valuable potential programme for the patients in care. Articles published so far depict the physiological, social and psychological output variables of animal assisted therapies. The enhancement of social behavior is considered to be a specific factor of animal assisted therapies. Among the physiological symptoms the enhanced physical activity, the decrease of stress response and sympathic activation have been highlighted. Among the psychological functions reduction of state anxiety, mood lift and the reduction of negative emotions such as isolation and abandonment should be underlined. Acknowledging the available results, it seems that cognitive efficacy is less impacted directly by animal assisted therapies. However, promising results have been acquired in the alleviation of the behavioural and psychological symptoms related to dementia ]