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Glucose and sodium tubular reabsorption inhibitors, or gliflozins, are a new therapeutic class. Their novel mechanism of action involves inhibition of a glucose and Na+ reabsorption co-transporter in the renal proximal tubule. They reduce blood glucose levels by reducing renal glucose reabsorption. They therefore cause glycosuria, which constitutes an energy loss and ultimately leads to a weight loss of around 2 to 3 kg. They reduce the sodium load and lower blood pressure. This class improves HbA1c by about 0.7%. Empagliflozin has been shown to reduce all-cause mortality in type 2 diabetic patients at high cardiovascular risk and to reduce episodes of cardiac decompensation and is nephroprotective in diabetic and non-diabetic subjects. Empagliflozin, like other gliflozins, does not induce hypoglycaemia as it does not directly stimulate insulin secretion. Due to the high prevalence of type 2 diabetes, heart failure and renal failure in the elderly, gliflozins will become part of geriatric prescriptions. Their advantages and use must be known, especially as their place will be extended to numerous indications in the field of chronic diseases.

This study aimed to determine whether visit-to-visit blood pressure (BP) variability (BPV) is associated with incident frailty. We included 1 394 nonfrail community-dwelling participants aged ≥70 years from the Multidomain Alzheimer Preventive Trial (MAPT) who underwent repeated clinical examinations, including BP and frailty, over a 5-year follow-up period. Systolic BPV (SBPV), diastolic BPV (DBPV), mean arterial pressure variability (MAPV), and pulse pressure variability (PPV) were evaluated using standard deviation (SD), coefficient of variation (CV), average real variability, successive variation, variation independent of mean, and residual SD. Incident frailty was assessed using the Fried phenotype. Cox proportional hazards models were used for the analyses. Higher SBPV was significantly associated with greater risk of frailty (1-SD increase of CV: hazard ratio [HR] = 1.18, 95% confidence interval [CI]: 1.02–1.36) after adjustment for demographics, systolic BP, antihypertensive drugs, body mass index, diabetes, ischemic heart disease, congestive heart failure, stroke, atrial fibrillation, MAPT randomization group, and frailty status. Similar results were observed with all indicators of variability. Higher PPV was associated with a greater risk of developing frailty over time (1-SD increase of CV: HR = 1.17, 95% CI: 1.01–1.35). DBPV and MAPV were not significantly associated with incident frailty. Higher SBPV and PPV were associated with greater risk of incident frailty. Our findings support the concept of BP physiological dysregulation underlying the frail state and suggest that BP instability could be an early marker of frailty.

The prevalence of heart failure increases with age. In France, the 1-year mortality rate is 35% in subjects aged 80-89 years with heart failure, and 50% after the age of 90 years. In octogenarians, heart failure is associated with high rates of cardiovascular and non-cardiovascular events, and is one of the main causes of hospitalization and disability. The prevalence of frailty increases in elderly subjects with heart failure, and the co-occurrence of heart failure and frailty increases the risk of mortality in patients with heart failure. In the elderly, the presence of frailty must be evaluated using a comprehensive geriatric assessment to manage geriatric syndromes, such as cognitive disorders, malnutrition, falls, depression, polypharmacy, disability and social isolation. The objective of heart failure therapy in octogenarians is to reduce symptoms, mortality and hospitalizations, but also to improve quality of life. In the absence of specific studies involving very old subjects, most recommendations are extrapolated from evidence-based data from younger populations. Overall, the epidemiological studies in patients with heart failure aged>80 years highlight the underprescription of recommended drugs. This underprescription may be related to comorbidity, a fear of side-effects and the lack of specific recommendations for drug prescription in heart failure with preserved ejection fraction, which is common in this very old population. The benefit/risk ratio related to heart failure treatment and comorbidity should be carefully weighed and reassessed on a regular basis. Consideration of disease prognosis according to factors that predict mortality can help to better define the care plan and promote palliative and supportive care when needed.

OBJECTIVES The aim of this study was to assess blood pressure (BP) control in patients with chronic kidney disease (CKD) according to office and home BP and to assess the prevalence of normal BP, white-coat uncontrolled hypertension (WUCH), masked uncontrolled hypertension (MUCH) and elevated BP. METHODS Patients with renal failure with or without proteinuria were included in this multicenter observational study. Office BP was first measured by the physician using a self-monitoring BP device (three automatic readings), then by the patient at home (morning and evening) over 3 consecutive days. WUCH was defined as a systolic BP (SBP)/diastolic BP (DBP) ≥140/90 mmHg in the clinic and SBP/DBP

Supplemental Digital Content is available in the text., Background and Purpose: The effects of direct oral anticoagulants in nonvalvular atrial fibrillation should be assessed in actual conditions of use. France has near-universal healthcare coverage with a unified healthcare information system, allowing large population-based analyses. NAXOS (Evaluation of Apixaban in Stroke and Systemic Embolism Prevention in Patients With Nonvalvular Atrial Fibrillation) aimed to compare the safety, effectiveness, and mortality of apixaban with vitamin K antagonists (VKAs), rivaroxaban, and dabigatran, in oral anticoagulant-naive patients with nonvalvular atrial fibrillation. Methods: This was an observational study using French National Health System claims data and including all adults with nonvalvular atrial fibrillation who initiated oral anticoagulant between 2014 and 2016. Outcomes of interest were major bleeding events leading to hospitalization (safety), stroke and systemic thromboembolic events (effectiveness), and all-cause mortality. Four approaches were used for comparative analyses: matching on propensity score (PS; 1:n); as a sensitivity analysis, matching on high-dimensional PS; adjustment on PS; and adjustment on known confounders. For each outcome, cumulative incidence rates accounting for competing risks of death were estimated. Results: Overall, 321 501 patients were analyzed, of whom 35.0%, 27.2%, 31.1%, and 6.6% initiated VKAs, apixaban, rivaroxaban, and dabigatran, respectively. Apixaban was associated with a lower PS–matched risk of major bleeding compared with VKAs (hazard ratio [HR], 0.43 [95% CI, 0.40–0.46]) and rivaroxaban (HR, 0.67 [95% CI, 0.63–0.72]), but not dabigatran (HR, 0.93 [95% CI, 0.81–1.08]). Apixaban was associated with a lower risk of stroke and systemic thromboembolic event compared with VKAs (HR, 0.60 [95% CI, 0.56–0.65]), but not rivaroxaban (HR, 1.05 [95% CI, 0.97–1.15]) or dabigatran (HR, 0.93 [95% CI, 0.78–1.11]). All-cause mortality was lower with apixaban than with VKAs, but not lower than with rivaroxaban or dabigatran. Conclusions: Apixaban was associated with superior safety, effectiveness, and lower mortality than VKAs; with superior safety than rivaroxaban and similar safety to dabigatran; and with similar effectiveness when compared with rivaroxaban or dabigatran. These observational data suggest potentially important differences in outcomes between direct oral anticoagulants, which should be explored in randomized trials.

Introduction Evidence regarding safety and efficacy of oral anticoagulants for the treatment of atrial fibrillation (AFib) in older adults has been assessed regarding the age appropriateness of oral anticoagulants (OAC) according to the FORTA (Fit fOR The Aged) classification (OAC-FORTA). Three years after its first version (OAC-FORTA 2016), an update was initiated to create OAC-FORTA 2019. Methods A structured review of randomized controlled clinical trials and summaries of individual product characteristics was performed to detect newly emerged evidence on oral anticoagulants in older patients with AFib. This review was used by an interdisciplinary panel of European experts (N = 10) in a Delphi process to label OACs according to FORTA. Results A total of 202 records were identified and 11 studies finally included. We found four new trials providing relevant data on efficacy and safety of warfarin, apixaban, dabigatran or rivaroxaban in older patients with AFib. In the majority of studies comparing the non-vitamin-K oral anticoagulants (NOACs) with warfarin, NOACs were superior to warfarin regarding at least one relevant clinical endpoint. The mean consensus coefficient significantly increased from 0.867 (OAC-FORTA 2016) to 0.931 (p 0.8). Warfarin, dabigatran, edoxaban and rivaroxaban were assigned to the FORTA B label, acenocoumarol, fluindione and phenprocoumon were labeled FORTA C and only apixaban was rated as FORTA A. Conclusion OAC-FORTA 2019 confirms that AFib can be successfully treated with positively labeled antithrombotics at advanced age. Electronic supplementary material The online version of this article (10.1007/s40266-020-00771-0) contains supplementary material, which is available to authorized users.

The coronavirus disease-2019 (COVID-19) is an infectious disease caused by severe acute respiratory syndrome coronavirus 2. The link between cardiovascular disease and COVID-19 appears to be twofold. First, some reports of data indicate that certain groups of patients are more at risk of COVID-19. This includes patients with cardiovascular risk factors or pre-existing cardiovascular conditions and older patients. In addition, these patients incur disproportionately worse outcome. Second, SARS-CoV2 infection can be complicated by life-threatening cardiovascular acute diseases. Despite the rapid evolution of data on this pandemic, this review aims to highlight the cardiovascular considerations related to COVID-19 whether as comorbidities including concerns and uncertainty regarding the effect of renin-angiotensin-aldosterone system (RAAS) inhibitors on angiotensin conversion enzyme 2 or related to acute cardiovascular complications.

ObjectiveDirect oral anticoagulants have been evaluated in the general population, but proper evidence for their safe use in the geriatric population is still missing. We compared the bleeding risk of a direct oral anticoagulant (rivaroxaban) and vitamin K antagonists (VKAs) among French geriatric patients with non-valvular atrial fibrillation (AF) aged ≥80 years.MethodsWe performed a sequential observational prospective cohort study, using data from 33 geriatric centres. The sample comprised 908 patients newly initiated on VKAs between September 2011 and September 2014 and 995 patients newly initiated on rivaroxaban between September 2014 and September 2017. Patients were followed up for up to 12 months. One-year risks of major, intracerebral, gastrointestinal bleedings, ischaemic stroke and all-cause mortality were compared between rivaroxaban-treated and VKA-treated patients with propensity score matching and Cox models.ResultsMajor bleeding risk was significantly lower in rivaroxaban-treated patients (7.4/100 patient-years) compared with VKA-treated patients (14.6/100 patient-years) after multivariate adjustment (HR 0.66; 95% CI 0.43 to 0.99) and in the propensity score–matched sample (HR 0.53; 95% CI 0.33 to 0.85). Intracerebral bleeding occurred less frequently in rivaroxaban-treated patients (1.3/100 patient-years) than in VKA-treated patients (4.0/100 patient-years), adjusted HR 0.59 (95% CI 0.24 to 1.44) and in the propensity score–matched sample HR 0.26 (95% CI 0.09 to 0.80). Major lower bleeding risk was largely driven by lower risk of intracerebral bleeding.ConclusionsOur study findings indicate that bleeding risk, largely driven by lower risk of intracerebral bleeding, is lower with rivaroxaban than with VKA in stroke prevention in patients ≥80 years old with non-valvular AF.

The authors thank Dr. Pinar Soysal for this comment on our article.1 We agree that the original standard diagnostic criteria of orthostatic hypotension (OHYPO), commonly based on supine-to-stand BP, are a reduction in systolic blood pressure (SBP) of at least 20 mm Hg or DBP of at least 10 mm Hg.2 The studies Dr. Pinar Soysal mentions assessed orthostatic BP response from a supine-to-standing position, which is not the case of the Health ABC Study. Indeed, given that the prevalence of OHYPO is higher in older adults and many of whom have comorbidities that may affect mobility, a sit-to-stand testing often offers a safer method to transfer a patient into an upright position without triggering an acute fall or syncopal event. Because of the reduced acute change in gravitational stress, the sit-to-stand test makes conventional BP cutoffs to diagnose OHYPO challenging to reach. An insignificant number of participants in the Health ABC Study had baseline OHYPO using that definition. Very recently, optimal diagnostic thresholds for the diagnosis of OHYPO with a sit-to-stand test have been proposed by Shaw et al.3 A sit-to-stand SBP drop of ≥15 mm Hg had optimal test characteristics (sensitivity = 80%; specificity = 89%), as did a DBP drop of ≥7 mm Hg (sensitivity and specificity both = 87%).3 We, therefore, used this threshold—consistent with previous large studies—including the Hypertension in the Very Elderly Trial (HYVET).4,5

International audience; Multidisciplinary management of worsening heart failure (HF) in the elderly improves survival. To ensure patients have access to adequate care, the current HF and French health authority guidelines advise establishing a clearly defined HF patient pathway. This pathway involves coordinating multiple disciplines to manage decompensating HF. Yet, recent registry data indicate that insufficient numbers of patients receive specialised cardiology care, which increases the risk of rehospitalisation and mortality. The patient pathway in France involves three key stages: presentation with decompensated HF, stabilisation within a hospital setting and transitional care back out into the community. In each of these three phases, HF diagnosis, severity and precipitating factors need to be promptly identified and managed. This is particularly pertinent in older, frail patients who may present with atypical symptoms or coexisting comorbidities and for whom geriatric evaluation may be needed or specific geriatric syndrome management implemented. In the transition phase, multi-professional post-discharge management must be coordinated with community health care professionals. When the patient is discharged, HF medication must be optimised, and patients educated about self-care and monitoring symptoms. This review provides practical guidance to clinicians managing worsening HF in the elderly.

Non-vitamin K antagonists oral anticoagulants (NOACs) have recently challenged vitamin-K antagonists (VKAs) for stroke and systemic embolism prophylaxis in patients with non-valvular atrial fibrillation (NVAF). Nevertheless, little information is available in routine clinical practice for France. The aim of this study is to describe the effectiveness and safety of apixaban, rivaroxaban, dabigatran or VKAs in routine clinical practice in adult NVAF patients for the prevention of stroke and systemic embolism in France. The NAXOS study is a nationwide observational retrospective cohort generated from the French national healthcare insurance database (SNIIRAM-a comprehensive in- and outpatient healthcare consumption database), consisting of eight distinct sub-cohorts of anticoagulant-naive or anticoagulant-experienced patients diagnosed with NVAF, newly initiated with either NOACs (dabigatran, rivaroxaban or apixaban) or VKAs. Patients will be included if initiating a new anticoagulant treatment for AF during the study period from 1 January 2014 to 31 December 2016. Primary effectiveness outcome will be the incidence of stroke or systemic thromboembolic events; primary safety outcome will be the incidence of major bleeding during the exposure period. The NAXOS study will provide routine clinical practice data on the effectiveness and safety profiles of apixaban vs other NOACs and VKAs in the prevention of stroke and systemic embolism in adult patients with NVAF in clinical practice conditions in France.

BACKGROUND Orthostatic hypotension (OH) measurement reproducibility is poor. Our objectives were to assess feasibility of self-detection home-measured OH (HOH) and HOH determinants. METHODS Subjects older than 65 years, attending a geriatric outpatient clinic, able to understand the HOH protocol: 3 blood pressure (BP) measures after 5 minutes of seating and BP measures after 1 and 3 minutes of standing, each morning and evening for 3 consecutive days were lent a validated digital automatic sphygmomanometer. Reports containing at least 4 correct measurements were deemed a success. Factors associated with HOH were studied. RESULTS HOH feasibility was 82.8% (241 subjects) with no difference between participants who failed or succeeded. Among the 241 subjects (mean age (SD) = 78.0 (8.3) years old; 62.1% of women), 139 were free of HOH, 70 had 1 HOH episode and 32 had 2 or more HOH episodes. Hypertension, dementia, atrial fibrillation, diabetes, and heart failure were found in 70.0%, 10.4%, 9.4%, 8.8%, and 3.4% of cases, respectively. Subjects were treated with antihypertensive, benzodiazepine, statin medication in 47.3%, 9.3%, 7.4% of cases, respectively, and 42.4% experienced polypharmacy. HOH episodes were associated with dementia (P = 0.01), presence of OH during the geriatric outpatient clinic assessment (P = 0.0002), statin therapy (P = 0.04), and polypharmacy (P = 0.0002). In multivariate analysis, benzodiazepine (OR (95% CI) = 2.59 (1.10–6.08) and statin medication (OR (95% CI) = 1.92 (1.10–3.33)) remained significantly associated with HOH. CONCLUSIONS HOH had a good feasibility and relevant determinants. A study to address the predictive value of HOH will be conducted.

After 80 years old, antihypertensive treatment significantly reduces cardiovascular events. In the elderly, blood pressure target depends on patients' frailty. After 80 years, French guidelines propose to aim a SBP

Background In older patients with cancer, depression is difficult to assess because of its heterogeneous clinical expression. The 4-item version of the Geriatric Depression Scale (GDS-4) is quick and easy to administer but has not been validated in this population. The present study was designed to test the diagnostic performance of the GDS-4 in a French cohort of older patients with cancer before treatment. Materials and Methods Our cross-sectional analysis of data from the Elderly Cancer Patient cohort covered all patients with cancer aged ≥70 years and referred for geriatric assessment at two centers in France between 2007 and 2018. The GDS-4’s psychometric properties were evaluated against three different measures of depression: the geriatrician's clinical diagnosis (based on a semistructured interview), the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders, and a cluster analysis. The scale's sensitivity, specificity, positive and negative likelihood ratios, and area under the receiver operating characteristic curve (AUROC) were calculated. Results In a sample of 2,293 patients (median age, 81 years; women, 46%), the GDS-4’s sensitivity and specificity for detecting physician-diagnosed depression were, respectively, 90% and 89%. The positive and negative likelihood ratios were 8.2 and 0.11, and the AUROC was 92%. When considering the subset of patients with data on all measures of depression, the sensitivity and specificity values were, respectively, ≥90% and ≥72%, the positive and negative likelihood ratios were, respectively, ≥3.4 and ≤ 0.11, and the AUROC was ≥91%. Conclusion The GDS-4 appears to be a clinically relevant, easy-to-use tool for routine depression screening in older patients with cancer. Implications for Practice Considering the overlap between symptoms of cancer and symptoms of depression, depression is particularly difficult to assess in older geriatric oncology and is associated with poor outcomes; there is a need for a routine psychological screening. Self-report instruments like the 4-item version of the Geriatric Depression Scale appears to be a clinically relevant, easy-to-use tool for routine depression screening in older patients with cancer. Asking four questions might enable physicians to screen older patients with cancer for depression and then guide them toward further clinical evaluation and appropriate care if required.

International audience; IntroductionStudies on the association of cancer and risk of dementia are inconclusive due to result heterogeneity and concerns of survivor bias and unmeasured confounding.MethodsThis study uses data from the Memento cohort, a French multicenter cohort following persons with either mild or isolated cognitive complaints for a median of 5 years. Illness‐death models (IDMs) were used to estimate transition‐specific hazard ratios (HRs) and 95% confidence intervals (CIs) for incident cancer in relation to dementia from time since study entry.ResultsThe analytical sample (N = 2258) excluded 65 individuals without follow‐up information. At the end of follow‐up, 286 individuals were diagnosed with dementia, 166 with incident cancer, and 95 died. Incident cancer was associated with a reduced risk of dementia (HR = 0.58, 95% CI = 0.35‐0.97), with a corresponding E‐value of 2.84 (lower CI = 1.21).DiscussionThis study supports a protective relationship between incident cancer and dementia, encouraging further investigations to understand potential underlying mechanisms.

Heart failure (HF) has high event rates, mortality, and is challenging to manage in clinical practice. Clinical management is complicated by complex therapeutic strategies in a population with a high prevalence of comorbidity and general frailty. In the last four years, an abundance of research has become available to support multidisciplinary management of heart failure from within the hospital through to discharge and primary care as well as supporting diagnosis and comorbidity management. Within the hospital setting, recent evidence supports sacubitril-valsartan combination in frail, deteriorating or de novo patients with LVEF ≤ 40%. Furthermore, new strategies such as SGLT2 inhibitors and vericiguat provide further benefit for patients with decompensating HF. Studies with tafamidis report major clinical benefits specifically for patients with ATTR cardiac amyloidosis, a remaining underdiagnosed and undertreated disease. New evidence for medical interventions supports his bundle pacing to reduce QRS width and improve haemodynamics as well as ICD defibrillation for non-ischemic cardiomyopathy. The Mitraclip reduces hospitalisations and mortality in patients with symptomatic, secondary mitral regurgitation and ablation reduces mortality and hospitalisations in patients with paroxysmal and persistent atrial fibrillation. In end-stage HF, the 2018 French Heart Allocation policy should improve access to heart transplants for stable, ambulatory patients and, mechanical circulatory support should be considered to avoid deteriorating on the waiting list. In the community, new evidence supports that improving discharge education, treatment and patient support improves outcomes. The authors believe that this review fills the gap between the guidelines and clinical practice and provides practical recommendations to improve HF management.

Background: Establishing an accurate prognosis remains challenging in older cancer patients because of the population’s heterogeneity. Using machine learning, we developed and externally validated a new predictive score (the “Geriatric Cancer Scoring System”, GCSS) to refine individualized prognosis for older patients with cancer during the first year following a geriatric assessment (GA). Methods: Data were collected from two French prospective multicentre cohorts of cancer patients aged 70 and over referred for GA: ELCAPA (training set, n=2012) and ONCODAGE (validation set, n=1397). Candidate predictors included baseline oncological and geriatric factors and routine biomarkers. Predictive models were built using Cox regression, single decision tree (DT), and random survival forest (RSF) methods, comparing their predictive performance for 3-, 6- and 12-month mortality by computing externally validated Harrell’s C-indices. Findings: At 12 months, respectively 875 (43%) and 219 (16%) patients in the training and validation sets had died (mean age at baseline: 81±6 and 78±5, respectively; women: 47% and 70%; metastatic cancer: 50% and 34%). Tumour site/metastatic status, cancer treatment, weight loss >3 kg (previous 3 months), 5 or more prescription drugs, Eastern Cooperative Oncology Group-Performance Status ≥2, Activities of Daily Living score ≤5, impaired timed up-and-go test, low creatinine clearance and elevated CRP/albumin were identified as independent predictors in the Cox model. DT and RSF identified more complex combinations of features, with the G-8 score, the tumour site/metastatic status and the CRP/albumin ratio contributing most to the predictions. The RSF approach gave the highest C-index (3 months: 0.91 [RSF], 0.88 [Cox], 0.87 [DT]; 12 months: 0.86 [RSF], 0.82 [Cox], 0.81 [DT]) and was thus retained as the final model. Interpretation: The GCSS based on a random forest machine learning approach gave an accurate externally validated 3-, 6- and 12-month mortality prediction. The GCSS might improve decision-making processes and counselling in older cancer patients. Funding Information: The ELCAPA study was funded by the French National Cancer Institute (Institut National du Cancer, INCa); Canceropole Ile-de-France; and Gerontopole Ile-de-France (Gerond’If). The ONCODAGE project was funded by the French National Cancer Institute (Institute National du Cancer); and SIRIC BRIO (Site de Recherche Integree sur le Cancer – Bordeaux Recherche Integree Oncologie; grant: INCa-DGOS-Inserm 6046). Declaration of Interests: None declared. Ethics Approval Statement: Two French prospective multicentre cohorts were considered in the present study. The study protocols were approved by the appropriate independent ethics committees (ELCAPA: CPP Ile-de-France I, Paris, France; ONCODAGE: CPP Sud-Ouest et Outre Mer III).

Introduction The clinical relevance of brain atrophy subtypes categorization in non-demented persons without a priori knowledge regarding their amyloid status or clinical presentation is unknown. Methods A total of 2083 outpatients with either subjective cognitive complaint or mild cognitive impairment at study entry were followed during 4 years (MEMENTO cohort). Atrophy subtypes were defined using baseline magnetic resonance imaging (MRI) and previously described algorithms. Results Typical/diffuse atrophy was associated with faster cognitive decline and the highest risk of developing dementia and Alzheimer's disease (AD) over time, both in the whole analytic sample and in amyloid-positive participants. Hippocampal-sparing and limbic-predominant atrophy were also associated with incident dementia, with faster cognitive decline in the limbic predominant atrophy group. Lewy body dementia was more frequent in the hippocampal-sparing and minimal/no atrophy groups. Discussion Atrophy subtypes categorization predicted different subsequent patterns of cognitive decline and rates of conversion to distinct etiologies of dementia in persons attending memory clinics.

Introduction: Visit-to-visit blood pressure variability (BPV) has been associated with greater cardiovascular and all-cause mortality, cognitive impairment, and incident dementia. It may also represent a decline in homeostatic mechanisms in blood pressure (BP) regulation associated with frailty, one of the most problematic expression of population aging. Hypothesis: We hypothesized that visit-to-visit systolic (SBPV), diastolic (DBPV), mean arterial (MAPV) and pulse pressure (PPV) variability are associated with greater incident frailty. Methods: We included 1,394 non-frail community-dwelling participants aged ≥ 70 years from the Multidomain Alzheimer Preventive Trial (MAPT) who underwent repeated clinical examinations over a 5-year follow-up period. SBPV, DBPV, MAPV and PPV were evaluated using standard deviation, coefficient of variation (CV), average real variability, successive variation, variation independent of mean and residual standard deviation. Incident frailty was assessed using the Fried phenotype. Cox proportional hazards models were used for the analyses. Results: Higher SBPV was significantly associated with increased risk of incident frailty (1-sd increase of CV: HR = 1.18, 95% CI [1.02-1.37], p=0.03) after adjustment for demographics, body mass index, stroke, ischemic heart disease, diabetes, heart failure, antihypertensive drugs, systolic BP, MAPT intervention groups and baseline pre-frail status. Similar results were observed with all indicators of variability. DBPV and MAPV were not associated with incident frailty (p=0.6 and p=0.2, respectively). Interestingly, higher PPV was also associated with a greater risk of developing frailty over time (1-sd increase of CV: HR = 1.17, 95% CI [1.01-1.35], p=0.03). Conclusion: Independently of BP, higher SBPV and PPV are major clinical predictors of incident frailty. Our findings support the concept of BP physiological dysregulation underlying the frail state and suggest that controlling BP instability could be a promising interventional target in preventing frailty.

Background In patients with non-valvular atrial fibrillation (NVAF), oral anticoagulants reduce the risk of stroke and systemic embolism, at the expense of an increased risk of bleeding. Purpose To compare the risk of bleeding and sites of bleeding according to the type of oral anticoagulant used in NVAF patients. Methods NAXOS is a population-based, historical cohort study including all patients aged ≥18 years with NVAF and newly initiating one of the OACs available in France between 2014 and 2016, aiming to compare safety, effectiveness, and all-cause mortality, according to the type of oral anticoagulant used. The French national health insurance reimbursement database, cross-linked with the hospitalisation database and civil status registry (SNIIRAM) was used to identify first users of oral anticoagulants and outcomes over their follow-up. Major bleeding events were identified through main diagnoses of hospital stays, with a specific focus on bleeding site. Apixaban was used as the reference treatment. Analyses were performed on crude data and with adjustment on propensity scores calculated separately for each of the comparators (VKAs, rivaroxaban and dabigatran). Results Overall, 321,501 NVAF patients were included: 87,565 (27.2%), 112,628 (35.0%), 100,063 (31.1%), and 21,245 (6.6%) initiated apixaban, VKAs, rivaroxaban, and dabigatran, respectively. The crude risks of intracranial bleeding were 0.45 [0.40–0.50], 1.23 [1.16–1.30], 0.48 [0.44–0.53], and 0.26 [0.19–0.34] per 100 patient-year, for apixaban, VKA, rivaroxaban, and dabigatran, respectively. The respective figures for gastro-intestinal bleeding were: 0.67 [0.61–0.74], 1.73 [1.64–1.81], 1.01 [0.94–1.08], 1.02 [0.89–1.17]; and those for non-intracranial and non-gastro-intestinal but other bleeding were: 0.84 [0.78–0.92], 2.22 [2.13–2.32], 1.24 [1.17–1.31] and 0.71 [0.60–0.84]. After adjustment on propensity-scores, patients initiating apixaban were at a lower risk of all major bleeding vs. VKA, rivaroxaban and dabigatran (HR=0.49 [0.46–0.52], 0.63 [0.58–0.67]) and 0.85 [0.76–0.95]). Apixaban was associated with a decreased risk of intracranial bleeding compared with VKAs (HR=0.46 [0.40–0.53]) and rivaroxaban (HR=0.80 [0.69–0.93]), and an increased risk compared with dabigatran (HR=1.53 [1.12–2.07]). The risk of gastro-intestinal bleeding was lower with apixaban than with VKAs (HR=0.57; [0.55–0.59]), rivaroxaban (HR=0.59; [0.52–0.66]), and dabigatran (HR=0.57; 0.48–0.68]). For other bleedings, apixaban was associated with a lower risk compared with VKAs (HR=0.47; [0.43–0.52]), and rivaroxaban (HR=0.59; [0.53–0.66]), and with a similar risk compared with dabigatran (HR=1.01; [0.84–1.23]). Conclusion In this large, real-world, population-based cohort, apixaban was associated with a lower risk of all types of bleedings requiring hospitalisation, compared with vitamin K antagonists. Differences between direct oral anticoagulants were also observed. Results of the comparative analyses Funding Acknowledgement Type of funding source: Private company. Main funding source(s): Bristol-Myers Squibb, Pfizer

Background Frailty and multimorbidity are common in patients with atrial fibrillation (AF). The quantifiable frailty phenotype has been validated as predictive of mortality and disability, and patients can be categorised as frail and non-frail using the Claims-based Frailty Index (CFI). The Charlson comorbidity index (CCI) is a tool to quantify multimorbidity and also a strong estimator of mortality. We evaluated whether frailty and multimorbidity are associated with the risk of major bleeding in patients with AF. Methods Based on the administrative hospital-discharge database, we collected information for all patients with AF between 2010 and 2019 in France. CCI and CFI were calculated for each patient, and their associated risks of bleeding compared to 4 bleeding risk scores (HAS-BLED, HEMORR2HAGES, ATRIA and ORBIT). The analysis focused on patients with events or with at least one year of follow-up. Predictive abilities of the scores were compared in the whole population, and then separately in the subgroup of elderly patients (>75 yo). Results Among 1,372,567 patients with AF, 131,535 major bleeding events were recorded during a follow-up of 3.5±2.1 years (median 3.1, IQR 1.8–4.9) (yearly rate 2.7%). Bleeding occurred more commonly in patients with higher HAS-BLED, ATRIA, CCI and CFI scores. Those with high frailty and multimorbidity had markedly higher yearly incidences of bleeding events of 13.0% and 14.7%, respectively (vs low frailty and multimorbidity: 4.3%% and 4.1%, respectively; p Conclusion Multimorbidity and frailty, respectively assessed with CCI and CFI, demonstrated statistically better performances in predicting major bleeding than the 4 established bleeding risk scores in AF. Funding Acknowledgement Type of funding source: None

Coronavirus disease 2019 (COVID-19) is a secondary infectious disease caused by severe acute respiratory syndrome coronavirus 2. The link between cardiovascular disease and COVID-19 appears to be twofold. First, some reports indicate that certain groups of patients are at greater risk of COVID-19, including patients with cardiovascular risk factors, pre-existing cardiovascular conditions and older patients. In addition, the outcomes these patients face are disproportionately more severe. Second, SARS-CoV-2 infection can be complicated by life-threatening acute cardiovascular diseases. Despite the rapid ongoing evolution of information about this pandemic, this review aims to highlight cardiovascular pathologies related to COVID-19 as either comorbidities, including concerns and uncertainty regarding the effect of renin-angiotensin-aldosterone system (RAAS) inhibitors on angiotensin conversion enzyme 2, or cardiovascular complications.

Objective The role of treatment with renin-angiotensin-aldosterone system blockers at the onset of COVID-19 infection is not known in geriatric population. The aim of this study was to assess the relationship between angiotensin receptor blockers (ARB) and an ACE inhibitor (ACEI) use and in-hospital mortality in geriatric patients hospitalized for COVID-19. Design This observational retrospective study was conducted in a French geriatric department. Patients were included between March 17 and April 18, 2020. Setting and Participants: All consecutive 201 patients hospitalized for COVID-19 (confirmed by RT-PCR methods) were included. All non-deceased patients had 30 days of follow-up and no patient was lost to follow-up. Methods Demographic, clinical, biological data and medications were collected. In-hospital mortality of patients treated or not by ACEI/ARB was analyzed using multivariate Cox models. Results Mean age of the population was 86.3 (8.0) years old, 62.7% of patients were institutionalized, 88.6% had dementia and 53.5% had severe disability (ADL score < 2). Sixty-three patients were treated with ACEI/ARB and 138 were not. Mean follow-up was 23.4 (10.0) days, 66 (33.8%) patients died after an average of 10.0 days (6.0). Lower mortality rate was observed in patients treated with ACEI/ARB compared with patients not treated with ARB nor ACEI (22.2% (14) vs. 37.7% (52), HR = 0.54 (95% CI = 0.30-0.97), p=0.03). In a multivariate Cox regression model including age, sex, ADL score, Charlson index, renal function, dyspnea, CRP and white blood cells count, use of ACEI/ARB was significantly associated with lower in-hospital mortality (HR = 0.52 (0.27−0.99), p=0.048). Conclusion and Implications In very old subjects hospitalized in geriatric settings for COVID-19, mortality was significantly lower in subjects treated with ARB or ACEI prior to the onset of infection. The continuation of ACEI/ARB therapy should be encouraged during periods of coronavirus outbreak in older subjects., In very old subjects hospitalized for COVID-19 in geriatric settings, mortality was significantly lower in those treated with ARB or ACEI prior to the onset of infection.

To investigate the impact of visit-to-visit systolic blood pressure variability (BPV), diastolic BPV, mean arterial pressure variability, and pulse pressure variability on cognitive decline and incident dementia in noninstitutionalized patients aged ≥65 years. A total of 3319 subjects from the S.AGES (Sujets AGÉS—Aged Subjects) cohort underwent clinical examinations every 6 months during 3 years. Variability was evaluated using standard deviation (SD), coefficient of variation, average real variability, successive variation, variation independent of mean, and residual SD. Cognition was assessed using the Mini-Mental State Examination and dementia with the Diagnostic Statistical Manual of Mental Disorders. Linear mixed models and Cox proportional hazards models were used. Higher systolic BPV was associated with poorer cognition independently of baseline SBP: adjusted 1-SD increase of coefficient of variation: β (SE)=−0.12 (0.06), P =0.04. Similar results were observed for diastolic BPV and mean arterial pressure variability: β (SE)=−0.20 (0.06), P P =0.02). Among the 3319 subjects, 93 (2.8%) developed dementia. Higher systolic BPV was associated with greater dementia risk (adjusted 1-SD increase of coefficient of variation: hazard ratios=1.23 [95% CI, 1.01–1.50], P =0.04). Similar results were found for diastolic BPV and mean arterial pressure variability ( P

Highlights • We report a screening campaign of asymptomatic staff workers in elderly nursing homes in Paris. • Before the campaign, 12.1% of the employees had developed symptomatic COVID-19. • Among screened employees not known to have the virus, 32/241 (13.3%) tested positive for SARS-CoV2. • Staff carrying SARS-CoV2 were asymptomatic in 75% of cases. • All in all, 66 out of 281 (23.5%) of the home employees had been carriers for COVID-19., Objectives To show that circulation of SARS-COV-2 in nursing homes in France can come from staff as well as residents’ families, whether they are known or not to have had COVID-19. Methods This study reports a screening campaign of asymptomatic staff working in elderly nursing homes in Paris where the virus had been circulating actively in March and April 2020. Results Before the screening campaign, the rate of symptomatic COVID-19 was 23.3% among the residents and 12.1% among their home employees. Within a 72 h screening period, all employees not known to have the virus were screened by RT-PCR in nasopharyngeal swabs. Among the 241 screened employees, 32 (13.3%) tested positive for SARS-CoV-2 on RT-PCR. SARS-CoV-2 carriers and non-carriers did not differ in term of gender, age or type of staff. Staff carrying SARS-CoV-2 were strictly asymptomatic in 75% of cases while during the days following or before the test, 25% presented mild symptoms of COVID-19. Considering both symptomatic and asymptomatic cases, 66 out of 281 (23.5%) of the home employees had been carriers for COVID-19. Conclusion Screening for viral carriage of asymptomatic staff in nursing homes can avoid contact and transmission to frequently severely vulnerable residents.

Potassium is involved in the voltage and excitability of the myocytes. Its homeostasis is dependent on dietary intake and its predominant renal elimination. The renin-angiotensin-aldosterone system regulates its elimination. Acute and chronic hyperkalemia is a risk factor for cardiac mortality. Chronic renal failure and heart failure are the major comorbidities. RAAS inhibitor therapies are the major iatrogenic factors in hyperkalemia. Approximately 90% of patients with hyperkalemia are over 50 years of age and 43% are over 75 years of age. Only 4.9% of hyperkalemias are managed with resin therapy. One-third of patients have 3 comorbidities, and 14% have 5 or more comorbidities. The main comorbidities are hypertension (74.0%), dyslipidemia (56.3%), renal failure (55.2%), diabetes (44.7%), coronary artery disease such as angina and myocardial infarction (23.3%) and heart failure (12%). It should be noted that 2/3 of the patients receiving resins were also receiving ARBSIs and tended to have more co-morbidities. Hyperkalemia is underestimated and requires strict monitoring in patients with renal failure or heart failure. Resins are not suitable for long-term adherence and new therapies such as patiromer would reduce the risk of hyperkalemia.

Objective: To investigate the impact of visit-to-visit systolic, diastolic, mean arterial pressure and pulse pressure variability on functional decline in non-institutionalized patients aged ≥ 65 years. Methods: 3042 subjects from the S.AGES (elderly subjects) cohort underwent clinical examinations every 6 months during 3 years. Systolic, diastolic, mean arterial pressure and pulse pressure variability were evaluated using standard deviation, coefficient of variation, average real variability, successive variation, variation independent of mean and residual standard deviation. Functional decline was assessed using the Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL) scales and defined over time as any help required to perform at least one task. Cox proportional hazards models were used for the analyses. Results: Among the 3042 subjects, 527 (17.3%) had functional decline (ADL) over time. After adjustment for demographics, systolic blood pressure, antihypertensive drugs, coronary artery disease, diabetes mellitus, chronic heart failure, atrial fibrillation, transient ischemic attack or stroke, smoking, dyslipidemia and Mini Mental State Examination at baseline, higher systolic blood pressure variability was associated with greater risk of functional decline (ADL) (adjusted HR per 1-SD increase of coefficient of variation = 1.12, 95% CI [1.03-1.22], p Conclusion: Higher blood pressure variability could be a novel risk factor for functional decline and controlling blood pressure instability a promising interventional target in preserving autonomy in older adults.

Background Optimal blood pressure in elderly patients after acute myocardial infarction is still a matter of debate. In a prospective observational study, we aimed to identify optimal systolic blood pressure during the 48 first hours after admission for acute myocardial infarction and its prognostic value for cardiovascular mortality. Methods and Results From the Observatoire des Infarctus de Côte d'Or survey, all consecutive patients aged >75 years admitted for an acute myocardial infarction in a coronary care unit from 2012 to 2015 and discharged alive were included (n=814). Exclusion criteria were in‐hospital death, cardiogenic shock, and end‐stage renal disease. Average systolic blood pressure ( aSBP ) values over the first 48 hours after admission were recorded, and the population was dichotomized into 2 groups: low aSBP group (aSBP ≥125 mm Hg). When compared with patients without cardiovascular death at 1‐year follow‐up, patients who died from a cardiovascular cause had higher rate of cardiovascular risks factors, including age, diabetes mellitus, comorbidities, and cardiovascular history. They had higher rates of low body mass index (2 ) and more elevated Global Registry of Acute Coronary Events risk score. Patients with aSBP P =0.008). By multivariable logistic regression analysis, low aSBP (odds ratio [95% CI ], 1.91 [1.07–3.41]) remained a strong and independent predictor of 1‐year cardiovascular mortality. Conclusions In our large population‐based study in elderly patients with acute myocardial infarction, low aSBP was an independent and powerful predictor of 1‐year cardiovascular mortality. Early aSBP measurement could help to improve risk stratification. Moreover, our results may suggest an optimal blood pressure target in elderly patients.

Background There is limited information describing the characteristics and outcomes of hospitalized older patients with confirmed coronavirus disease 2019 (COVID-19). Method We conducted a multicentric retrospective cohort study in 13 acute COVID-19 geriatric wards, from March 13 to April 15, 2020, in Paris area. All consecutive patients aged 70 years and older, with confirmed COVID-19, were enrolled. Results Of the 821 patients included in the study, the mean (SD) age was 86 (7) years; 58% were female; 85% had ≥2 comorbidities; 29% lived in an institution; and the median [interquartile range] Activities of Daily Living scale (ADL) score was 4 [2–6]. The most common symptoms at COVID-19 onset were asthenia (63%), fever (55%), dyspnea (45%), dry cough (45%), and delirium (25%). The in-hospital mortality was 31% (95% confidence interval [CI] 27–33). On multivariate analysis, at COVID-19 onset, the probability of in-hospital mortality was increased with male gender (odds ratio [OR] 1.85; 95% CI 1.30–2.63), ADL score Conclusions This study provides new information about older patients with COVID-19 who are hospitalized. A quick bedside evaluation at admission of sex, functional status, systolic arterial pressure, consciousness, respiratory rate, and asthenia can identify older patients at risk of unfavorable outcomes.

OBJECTIVE Caregivers do not usually use services that could alleviate their burden. The objectives were to determine the refusal's prevalence and the reasons why informal caregivers of demented patients refuse clinic medico-psycho-social assessment in the first day care hospital dedicated to caregivers in France. METHODS Caregivers of patients hospitalized in geriatric ward were prospectively asked to fill in a questionnaire (demographic data, risk for depression and caregiver burden (Zarit scale) about their willingness to benefit from a clinic checkup. If caregivers refused eleven close questions were asked. Characteristics of the caregivers were compared according to the caregivers' agreement or refusal to the clinic checkup. RESULTS Seventy-seven caregivers (mean age (standard deviation): 68.2 (11.5)) were included: 68.8% of women, 51.9% of children and 35.1% of spouses, mean Zarit scale score was 32.8 (8.8)/88. Clinic checkup was accepted by 28 caregivers. Agreement was associated with exhaustion (p

Aims The main aim of the present work was to assess if sex influences the occurrence of major clinical events in elderly people with type 2 diabetes followed up in the primary care. Methods 983 subjects aged ≥65years with type 2 diabetes were included by 213 general practitioners and followed up prospectively for three years. Major clinical events were recorded every six month. The first endpoint was a composite of all-cause death and major vascular events (acute coronary syndrome, non-fatal stroke or transient ischemic attack, or revascularization for peripheral artery disease). The second endpoint was all-cause hospitalization. The occurrence of each endpoint was analyzed in order to estimate the role of sex and determine other predictors of major clinical events. Results At baseline, women were older than men but they had a lower prevalence of coexisting diseases (cardiovascular disease and cancer) and equivalent diabetes control (Glycated hemoglobin A1C: 6.9%±0.9 vs. 7.0%±1.1). Over the follow-up period, women were at lower risk to develop the composite endpoint (HR 0.60, 95% CI 0.40-0.91, p=0.016) and the hospitalization endpoint (OR 0.71, 95% CI 0.52-0.96, p=0.029). Coexisting diseases, functional ability and concomitant medications emerged as significant predictors of both endpoints. Conclusions Elderly women with well-controlled type 2 diabetes were less likely to experience major clinical events than their male counterparts. More studies are needed to determine the reasons for the higher hospitalization rate in men.

Atrial fibrillation (AF) is the most common arrhythmia and its prevalence increases with age. Age also increases the risk of thromboembolism related to AF. As a result, elderly patients are at increased risk of AF-related stroke compared to younger patients. Age, however, also increases the risk of bleeding, including that of intracranial haemorrhage, an important cause of death and disability. Elderly patients with AF are, therefore, often undertreated due to the fear of bleeding complications, although recent data suggest an even greater net clinical benefit for anticoagulation in general in the elderly, even the very elderly, compared with younger patients. The non-vitamin K antagonist oral anticoagulants (NOACs), such as dabigatran, rivaroxaban, apixaban and edoxaban, have become popular alternatives to vitamin K antagonists (VKAs) for anticoagulation in AF. The improved safety profile of NOACs may enable treatment of elderly patients that were previously untreated, further improving on this net clinical benefit. However, a number of factors, including renal impairment and multiple comorbidities, may elicit in elderly patients concerns with NOACs that are not seen in younger patients. Recent clinical data suggest that the use of NOACs offers a safer alternative to VKAs. However, on the basis of current evidence, it is not possible to simply recommend one NOAC over another in elderly adults. A personalised approach is recommended, accounting for individual patient factors.

Resume Objectif L’utilisation d’une echelle visuelle pour evaluer l’observance des traitements antihypertenseurs a montre sa bonne concordance avec l’evaluation de l’observance par pilulier electronique. L’utilisation de l’echelle visuelle EvalObs® dans une large population de sujets traites pour une HTA, une dyslipidemie ou un diabete est l’objectif de l’etude FLAHS 2017 ainsi que l’etude de la concordance entre EvalObs® et le questionnaire d’observance de Girerd chez des hypertendus. Methode Les enquetes FLAHS sont realisees par autoquestionnaire envoye par courrier a des individus issus de la base de sondage permanente Metascope de TNS SOFRES (panel representatif de la population vivant en France metropolitaine). En 2017, FLAHS a ete realise chez 4783 sujets âges de 35 ans et plus. L’echelle visuelle EvalObs ® comporte une graduation de 0 a 15 et l’instruction d’utilisation est « combien de jours avez-vous pris le medicament au cours des 15 derniers jours ». Un score > 12 indique une « bonne observance ». Pour le questionnaire de Girerd, un score de 3 ou plus ou une absence de remplissage est consideree comme « mauvaise observance » et la concordance avec EvalObs® a ete evaluee chez les hypertendus. Resultats FLAHS 2017 a inclus 4783 sujets comportant 1308 hypertendus traites, 942 sujets traites pour le cholesterol et 405 sujets traites pour le diabete. Avec le questionnaire de Girerd, une « mauvaise observance » est notee chez 5,1 % des hypertendus et est plus elevee chez les hommes (6,7 %) que chez les femmes (3,5 %). La mauvaise observance est plus frequente chez les sujets de 35 a 44 ans (11,3 %) et chez les 80 ans et plus (8,4 %) par comparaison aux sujets de 45 a 79 ans (4,2 %). Avec EvalObs®, la « mauvaise observance » est de 8,2 % [IC 95 ; 6,5–9,9] au cours du traitement du cholesterol, de 6,0 % [CI 95 ; 3,9–8,1] au cours du traitement du diabete et de 3,6 % [CI 95, 2,5–4,7] au cours du traitement de l’hypertension. Chez l’hypertendu, la comparaison du questionnaire de Girerd et d’EvalObs® trouve une concordance a 93,8 %. Conclusion L’usage d’une echelle visuelle d’observance dans la population de FLAHS 2017 indique que l’observance des traitements de l’hypertension, du diabete et du cholesterol est differente. L’echelle visuelle EvalObs® en complement du questionnaire de Girerd permet une rapide evaluation de l’observance au cours des maladies. EvalObs est disponible gratuitement sur Appel store et Google play.

Summary Background Atrial fibrillation (AF) is the most common arrhythmia worldwide, and its prevalence is expected to increase with population ageing. The use of vitamin K antagonists (VKAs) for the prevention of stroke and/or systemic embolism in patients with non-valvular atrial fibrillation (NVAF) was recently challenged by non-VKA oral anticoagulants (NOACs), demonstrating a favourable risk-benefit profile, with reductions in stroke, intracranial haemorrhage and mortality, similar major bleeding, but increased gastrointestinal bleeding. Nevertheless, data on their use in a “real-life” setting are scarce for France. Aims To compare the characteristics of patients with AF newly anticoagulated with either VKAs or NOACs, to describe the reasons for discontinuing the previous anticoagulant strategy and/or choosing the newly initiated anticoagulant treatment, and to precisely describe the prescriptions of patients newly initiated with apixaban. Methods This is a nationwide multicentre non-interventional cross-sectional study conducted in patients with AF by a representative stratified sample of cardiologists in France. Over a 12-month accrual period, consecutive patients aged ≥ 18 years with NVAF, for whom anticoagulant treatment (VKAs or NOACs) has been initiated within the last three months before the index consultation, will be included. The primary outcome will be the comparison of anticoagulant-naive patient characteristics, co-morbidities and treatment history among the anticoagulant subgroups. Secondary endpoints will include a description of the reasons for discontinuing the previous anticoagulant strategy and/or for initiating and choosing the newly initiated anticoagulant treatment, as well as the prescription conditions of apixaban. Conclusion The PAROS study will provide real-life data on the characteristics of NVAF patients and their anticoagulant prescription in France.

Peripheral inflammatory processes are involved in Alzheimer's disease (AD). We aimed to determine whether plasma inflammatory mediator levels at diagnosis are associated with cognitive decline through a 2-year follow-up in AD patients. Patients (n = 109, mean age 79.44 (6.82) years) were included at diagnosis with MMSE scores between 16 and 25, with C-reactive protein

Background Olfactory impairment is reported in mild cognitive impairment (MCI) and Alzheimer's disease (AD) and is associated with hippocampal atrophy. In elderly people, dementia with AD neuropathology and white matter lesions (WML) is common. In this context, olfactory impairment could also depend on the presence of WML. Objective To assess the cross-sectional relationship between olfaction and WML in elderly subjects with MCI. Methods Consecutive subjects, >65 years old, diagnosed as MCI after a comprehensive neuropsychological assessment in an expert memory center, with a brain MRI performed within a year and without major depressive state, were included. Olfaction was assessed by the Brief Smell Identification Test (BSIT). Two trained neuroradiologists, blind to cognitive and olfaction status, visually assessed hippocampal atrophy according to Scheltens' scale and WML according to Fazekas criteria. Results Seventy-five MCI subjects (mean age (SD) = 77.1 (6.2) years, 74.7% of women) were included. After adjustment for age and sex, factors associated with low BSIT scores were older age (p = 0.007), lower BMI (p = 0.08), lower MMSE score (p = 0.05), lower FCRST (p = 0.008), hippocampal atrophy (p = 0.04), periventricular WML (p = 0.007), and deep WML burden (p = 0.005). In multivariate analysis, severe deep WML (OR (95% CI) = 6.29 (1.4-35.13), p = 0.02) remained associated with low BSIT score independently from hippocampal atrophy. Conclusion In elderly MCI subjects, low olfactory performances are associated with WML, whose progression may be slowed by vascular treatments. A longitudinal study to evaluate whether the progression of WML, hippocampal atrophy and low olfactory function, can predict accurately conversion from MCI to dementia is ongoing.

Few geriatric patients were included in studies on direct oral anticoagulants and data on dabigatran concentration and safety are needed in this population. Our objectives were to evaluate peak and trough dabigatran plasma concentrations over time in a geriatric population and to identify factors associated with dabigatran plasma concentrations and to assess the relationship with bleeding events. Peak and trough dabigatran plasma concentration were performed 4,8,15,30,45 days after inception of dabigatran treatment in 68 consecutive patients≥75 years old hospitalized in a geriatric hospital with atrial fibrillation. Bleeding events were monitored for 1 year. Mean age was 85.8(5.1) years old and 76.5% were women. Overall, 541 dabigatran plasma measurements (270 peak, 271 trough) were performed. Mean dabigatran concentrations of the 5 sequential measurements ranged 106-146ng/mL for peak and 66-84ng/mL for trough. Renal failure was associated with high peak and trough dabigatran concentration. Inter- and intra-individual coefficients of variation were 59.5% and 44.7% for peak and 74.5% and 44.6% for trough. Participants in the lower two tertiles of dabigatran concentration at day 8 (D8) remained below the 90th percentile (243.9ng/ml) on the next measurements. Bleeding events were associated with high trough dabigatran concentrations. Trough dabigatran concentration at D8>243.9ng/mL significantly predicted bleeding. In this geriatric population, renal function and low albumin were associated with dabigatran concentrations. Despite large variability, participants in the lower two tertiles of dabigatran concentration at D8 remained below the 90th percentile on the following measurements. D8 dabigatran trough concentration≥243.9ng/mL identified patients at risk of bleeding.

Objective: Evaluate the occurrence of COVID-19 in the first half of 2020 in treated hypertensive patients and describe their medical follow-up during lockdown. Design and method: The FLAHS 2020 survey was performed in July/August 2020 by a self-administered questionnaire sent to 6,000 individuals aged 35 years and over from Kantar Health's Metascope permanent sampling base (a representative panel of the population living in metropolitan France). A subject was declared ill with COVID if he answered Yes to the question: Have you been ill with COVID-19 with a diagnosis confirmed or not by a doctor? The representativeness of the results for the metropolitan French population was performed by adjusting the data on geographical area, living conditions, socioeconomic category, gender and age. Results: Among the 4069 adults aged 35 years and older, symptomatic COVID-19 was reported by 2.2% [CI95:1.9-2.5] of respondents. The prevalence was 2.7% [CI95:1.4-4.0] among those treated with antihypertensive medication, 2.0% [1.7-2.3] among those not treated, 1.9% [1.3-2.5] among men and 2.5% [1.9-3.1] among women. Among subjects reporting COVID-19. During lockdown, 61.9% of treated hypertensive patients [60.6-63.2] were able to have medical contact, of which 9.8% [8.5-11.1] was by telephone and 5.9% [4.6-7.2] by videoconsultation, which was more frequent in the 35-54 age group with 13.1% [12.5-16.7] than in the 75+ age group with 3.5% [1.2-5.5]. 81.4% [2.8-5.4] of treated hypertensive patients visited the pharmacy at least once, and 4.1% [2.8-5.4] had their treatment delivered at home. Discontinuation of usual treatment was reported by 0.9% [0-2.2] of hypertensive patients, with a higher frequency in those aged 75 years and over (1.7% [0-4.0]). Conclusions: In the first half of 2020 in metropolitan France, COVID-19 in its symptomatic and self-reported form concerned treated hypertensive patients and the general population in a similar way. During lockdown there was no obvious disruption of care in the treated hypertensive patients and teleconsultation had a significant development, particularly for the visio-consultation in the 35-54 age group.

Introduction From a patient-centered perspective, the assessment of risk factors of hypoglycemia is of critical importance for the management of type 2 diabetes (T2D). However, the association between the occurrence of hypoglycemia and high burden of comorbidities has been poorly studied in vulnerable older patients. Here, we aimed to determine whether a high burden of comorbidities is associated with hypoglycemia in very old patients with T2D. Methods A total of 1552 elderly (age ≥ 80 years old) patients with T2D were recruited in a nationwide cross-sectional study performed in French geriatric care units. Hypoglycemia was defined as a confirmed blood glucose value level ≤ 70 mg/dL. Comorbidities were assessed using the Charlson Comorbidity Index (CCI). Results Amongst the 1552 recruited patients (mean age 86.4 years), 415 (26.7%) had documented hypoglycemia. Compared to patients in whom hypoglycemia was not reported, they have a lower body weight (p = 0.004), a reduced eGFR (p

Resume Objectif Rechercher les determinants d’une inobservance aux traitements antihypertenseurs chez les participants de l’enquete FLAHS 2015 et mettre au point un calculateur de ce risque pour une population d’hypertendus. Methode Les enquetes FLAHS sont realisees par autoquestionnaire envoye par courrier a des individus issus de la base de sondage permanente Metascope de TNS SOFRES (panel representatif de la population vivant en France metropolitaine). En 2015, FLAHS a ete realise chez les sujets âges de 55 ans et plus. Les sujets declarant etre sous traitement antihypertenseur et ayant repondu aux 6 questions du questionnaire de Girerd ont constitue la base pour l’analyse. La variable « parfaite observance » a ete determinee pour un score a 0 et « l’inobservance » pour un score de 1 ou plus. Une regression de Poisson a ete menee en univarie et multivarie permettant d’estimer les rapports de risque pour chaque determinant. Un calculateur de risque d’inobservance est construit a partir de l’analyse multivariee. Pour chaque sexe, une table de probabilite a ete produite selon le calcul de l’equation multivariee et le risque relatif d’inobservance (RI) a ete calcule en prenant comme reference le profil du patient avec la meilleure observance pour chaque sexe. Pour chaque sujet teste, il est attribue une des trois classes du risque d’inobservance : faible (RI = 1,5 et Resultats L’enquete a inclus 6379 sujets et l’analyse basee sur 2370 hypertendus traites. Le debut du traitement etait inferieur a 2 ans chez 7 % des sujets et la mediane de duree de suivi d’un traitement etait de 10 ans. Une parfaite observance est retrouvee chez 64 % des sujets. Les determinants independants de l’inobservance sont : le sexe masculin, le jeune âge, le nombre eleve de comprime antihypertenseur, la prise d’un traitement pour une maladie metabolique (diabete, dyslipidemie), la presence d’une maladie chronique autre (cancer, musculaire-articulaire-osseuse, psy), la situation de prevention secondaire d’une maladie cardiovasculaire. Le calcul du risque d’inobservance est disponible en ligne sur http://www.comitehta.org/flahs-observance-hta/ . Conclusion La mise au point de FLAHS Observance rend possible une estimation du risque d’inobservance en consultation. Cet outil fait partie de l’action « agir pour l’observance » propose par Hypertension France en 2017.

Dementia is a worldwide health concern, which leads to loss of autonomy. To date no curative treatment is available so focus on modifiable risk factors is of particular interest. Hypertension, particularly midlife high blood pressure, has been associated with an increased risk for cognitive decline and dementia including vascular dementia (VAD) and Alzheimer disease (AD). In this context, antihypertensive treatments might have a preventive effect. The objective of this review was to examine the relationship between antihypertensive therapy and cognitive decline or dementia. Areas covered: A literature search was conducted using PUBMED and the COCHRANE LIBRARY for publications from 1990 onwards mentioning cognitive decline, AD, Vad, mixed dementia, vascular cognitive impairment, hypertension and antihypertensive therapy. Thirty-nine relevant publications including 20 longitudinal studies, 10 randomized-controlled trials and 9 meta-analyses were taken into account. Expert opinion: Most observational studies have suggested a potential preventive effect of antihypertensive therapies on cognitive decline and dementia, particularly calcium channel blockers and renin-angiotensin system blockers. Randomized clinical trials and meta-analyses provided more conflicting results potentially due to methodological issues. In conclusion, antihypertensive therapies may reduce cognitive decline and incidence of dementia. Further randomized clinical trials conducted in populations at higher risk of cognitive decline, with longer periods of follow-up and cognition as the primary outcome are still needed.