782
LETTERS TO THE EDITOR
compression suit. Pressures generated from the different methods varied from 15 to 60 mmHg, where reported. The various outcome measures used are detailed in Table 1. When symptoms were reported, they were assessed using unvalidated methods. All studies assessed orthostatic BP response in a single observation, with Study A also assessing symptoms after 1 month of use of compression bandages. Of the three studies that assessed symptoms (A, B, D), two reported a statistically significant reduction in symptoms during testing with compression bandages, and the other reported increasing improvement in symptoms with different levels of external compression. Of the two studies that used the lying-to-sitting method, one found a decrease in the prevalence of OH with compression, whereas the other did not. Study B did not report change in BP, the other four all reported a significant reduction in the BP drop or a significant increase in BP with compression. Study A, which reported symptoms after 1 month of lower limb compression, found a significant reduction in symptoms and an adherence rate of 71%. Although the aim was to perform a systematic review and meta-analysis of the use of lower limb compression in the treatment of OH, it was not possible because of the quantity and quality of the studies available. The focus of the studies was observational, using compression during a single orthostatic challenge. Only one study assessed the effects beyond a single episode, but this was not controlled, randomized or blinded. Although these studies were small and had significant weaknesses, they provide a small degree of support for the use of lower limb compression, although the evidence is weak and is more supportive of investigating their use further than of a clinical intervention. Lower limb and abdominal compression is arguably not a simple intervention. It is time consuming and difficult to fit, and many older people would struggle to use the necessary devices. If such measures are to be recommended for older people in the treatment of OH, these recommendations should be based on good evidence. A clinical trial of the use of compression to treat OH would be timely now; the prevalence of OH is increasing, and the results would be far reaching. James Frith, PhD Julia L. Newton, PhD Biomedical Research Centre in Ageing and Age Related Diseases, National Institute for Health Research, Institute for Ageing and Health, Newcastle University, Newcastle, UK
ACKNOWLEDGMENTS Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: Frith: concept and design, independent article review, principle author. Newton: independent article review, author contributor. Sponsor’s Role: None.
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REFERENCES 1. Shiboa C. Orthostatic hypotension related hospital admissions in the United States. Am J Med 1990;113:308–316. 2. Lahrmann H, Cortelli P, Hilz M et al. EFNS guidelines on the diagnosis and management of orthostatic hypotension. Eur J Neurol 2006;13:930– 936. 3. Podoleanu C, Maggi R, Brignole M et al. Lower limb and abdominal compression bandages prevent progressive orthostatic hypotension in elderly persons: A randomized single-blind controlled study. J Am Coll Cardiol 2006;48:1425–1432. 4. Gorelik O, Fishlev G, Almoznino-Sarafian D et al. Lower limb compression bandaging is effective in preventing signs and symptoms of seating-induced postural hypotension. Cardiology 2004;102:177–183. 5. Smit AA, Wieling W, Fujimura J et al. Use of lower abdominal compression to combat orthostatic hypotension in patients with autonomic dysfunction. Clin Auton Res 2004;14:167–175. 6. Denq JC, Opfer-Gehrking TL, Giuliani M et al. Efficacy of compression of different capacitance beds in the amelioration of orthostatic hypotension. Clin Auton Res 1997;7:321–326. 7. Gorelik O, Almoznino-Sarafian D, Litvinov V et al. Seating-induced postural hypotension is common in older patients with decompensated heart failure and may be prevented by lower limb compression bandaging. Clin Auton Res 2009;55:138–144.
AVOIDING EMERGENCY DEPARTMENT ADMISSIONS USING TELEPHONIC CONSULTATIONS BETWEEN GENERAL PRACTITIONERS AND HOSPITAL GERIATRICIANS To the Editor: Elderly people are four times as likely to be hospitalized as younger age groups and may occupy hospital beds for longer periods of time.1 Individuals aged 75 and older are frequently hospitalized, often in an unplanned way, which leads to longer hospital stays and iatrogenic complications, especially functional decline.2 Numerous studies and meta-analyses have tried to determine how to decrease emergency department (ED) admissions and readmissions for older adults.3–8 Most have found that better hospital discharge organization significantly reduces the risk of early readmission (within 30 days) (discharge planning and short, structured, discharge summaries accessible over the Internet). The literature also shows that improving communications with community care physicians may enhance care, and reduce the rate of ED admissions and early readmissions. The aim of this study was to evaluate the effect of a telephone hotline in assisting general practitioners in their decisionmaking to improve and smooth the transition of older adults to the hospital.
METHODS Representatives of the Regional Union of General Practitioners of the southwest of France (Aquitaine) and the Department of Geriatrics and the administration of the University Hospital of Bordeaux set up this experiment in November 2010. The goals of this hotline were to meet the expectations of general practitioners by allowing a direct call with a geriatrician every day, Monday to Friday (9 a.m.–7 p.m.) and to give medical advice and alternatives to ED admissions (planned geriatric consultations, day hospital, or geriatric medicine hospitalizations). The telephone switchboard of the University Hospital of
JAGS
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783
Table 1. Solutions Given to General Practitioners According to the Reasons for the Hotline Calls (N = 228)
Characteristic
Age, mean SD Living alone, n (%) Living in a nursing home, n (%) Behavioral disorder, n (%) Unexplained asthenia, n (%) Social problems, n (%) Repeated falls, n (%)
Medical Advice, n = 87
86.5 7.5 19 (23.5) 30 (53.6) 31 13 8 4
(46.9) (34.2) (34.8) (13.8)
Consultation or Hospital Day, n = 33
85.2 4.8 15 (18.5) 4 (7.1) 9 4 8 7
(13.6) (10.5) (34.8) (24.1)
Planned Hospitalization, n = 98
86.6 5.3 45 (55.6) 19 (3.4) 26 21 7 17
(39.4) (55.3) (30.4) (58.6)
Emergency Department Admission, n = 10
P-Value
85.0 7.3 2 (2.5) 3 (5.4)
.52 .002 .04
0 0 0 1
(0.0) (0.0) (0.0) (3.4)
.15 .03 .02 .003
Bordeaux routinely quantified all telephone calls. All of the geriatricians in charge of this hotline recorded data regarding the reasons for calls, solutions proposed to general practitioners, and patient characteristics, including sociodemographic data, level of autonomy, comorbidities, and medical problems. All of the general practitioners were asked how they would have handled each situation if the hotline had not been available (e.g., emergency admission). Statistical analyses were performed using SPSS 11.5 (SPSS Inc., Chicago, IL). Continuous variables were compared using t-tests, dichotomous variables using chisquare tests, and multiple comparisons using analysis of variance.
hotline might be a good tool for improving integrated care of older adults.
RESULTS
Virginie Valentin, Direction of the University Hospital of Bordeaux, Talence, France
Seven hundred fourteen calls were recorded from November 2010 to February 2012 for the management of 230 older adults (mean age 86.2 6.2). Most of the individuals included lived at home (70.7%), and 60% of these lived alone. The calls were mostly about the management of behavioral disorders (29.5%), unexplained asthenia (17%), repeated falls (13%), treatment of acute diseases such as cardiac insufficiency or infection (12.5%), and complex social problems (10.3%). Only 4.3% of individuals were directly admitted to the ED, and the hotline permitted the avoidance of ED admissions in 81.4% of cases. The responses of the geriatricians in charge of this hotline were to give medical advice to the general practitioners (38.3%) or to schedule a geriatric consultation (5.3%), a day hospital visit (9.2%), or hospitalization in a geriatrics ward (42.9%). As shown in Table 1, a planned hospitalization in a geriatric ward was an alternative to ED admission for individuals with repeated falls, unexplained asthenia, or living alone. Only a few studies have reported results on the efficacy of such a hotline for general practitioners. Data have mainly focused on gaps in continuity of care at the interface between primary care and specialized care after hospitalization. Nevertheless, alternative models of care are reported, including primary prevention programs, programs of care including self-management and pharmaceutical programs, and prehospital comprehensive geriatric assessment.8 In conclusion, this hotline allowed prompt answers to general practitioners’ questions, improved and streamlined the transition of older adults to the hospital, and assisted general practitioners in their decisions. This
Nathalie Salles, MD, PhD Marie Floccia, MD Marie-Neige Videau, MD Leila Diallo, MD P^ ole de Gerontologie Clinique, H^ opital Xavier-Arnozan, Centre Hospitalier Universitaire de Bordeaux, Pessac, France Dany Guerin, MD Regional Union of General Practitioners Aquitaine, Bordeaux, France
Muriel Rainfray, MD, PhD P^ ole de Gerontologie Clinique, H^ opital Xavier-Arnozan, Centre Hospitalier Universitaire de Bordeaux, Pessac, France
ACKNOWLEDGMENTS N. Salles, L. Diallo, M. N. Videau, M. Floccia, M. Rainfray. Does a hotline for General Practitioners improve the care of older frail patients? A pilot study. 9th Congress of the EUGMS, Venice, Italy, October 2013. N Salles, L Diallo, MN Videau, M Floccia, J Charrieau, M Rainfray. Does a hotline for General Practitioners improve the care of older frail patients? A pilot study. 20th IAGG World Congress of Gerontology and Geriatrics, Seoul, Korea, June 2013. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: All authors: design and interpretation. Salles: statistical analysis, interpretation of data, writing the paper. Floccia, Videau, Diallo: data collection. Guerin, Valentin, Rainfray: study conception. Sponsor’s Role: No commercial company sponsored or played any role in the design, methods, subject recruitment, data collection, analysis, or preparation of this letter.
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LETTERS TO THE EDITOR
REFERENCES 1. Wallace E, Hinchey T, Dimitrov BD et al. A systematic review of the probability of repeated admission score in community-dwelling adults. J Am Geriatr Soc 2013;61:357–364. 2. Graf C. Functional decline in hospitalized older adults. Am J Nurs 2006;106:58–67, quiz 67–58. 3. Allen J, Ottmann G, Roberts G. Multi-professional communication for older people in transitional care: A review of the literature. Int J Older People Nurs 2013;8:253–269. 4. Bunn F, Byrne G, Kendall S. Telephone consultation and triage: Effects on health care use and patient satisfaction. Cochrane Database Syst Rev 2004; Issue 3. Art. No:CD004180. doi: 10.1002/14651858.CD004180.pub2 5. Hesselink G, Schoonhoven L, Barach P et al. Improving patient handovers from hospital to primary care: A systematic review. Ann Intern Med 2012;157:417–428. 6. Parker SG, Peet SM, McPherson A et al. A systematic review of discharge arrangements for older people. Health Technol Assess 2002;6:1–183. 7. Rennke S, Nguyen OK, Shoeb MH et al. Hospital-initiated transitional care interventions as a patient safety strategy: A systematic review. Ann Intern Med 2013;158:433–440. 8. Shepperd S, Lannin NA, Clemson LM et al. Discharge planning from hospital to home. Cochrane Database Syst Rev 2013;Issue 1. Art. No.: CD000313. doi: 10.1002/14651858.CD000313.pub4
ARTERIAL COMPLIANCE PLATEAUS IN HEALTHY AGING WOMEN—IN TIME FOR PREVENTIVE TREATMENT To the Editor: The increasing prevalence of cardiovascular diseases with advancing age is placing a growing burden on society and healthcare systems worldwide, making it crucial to identify the optimal time for effective prevention, before evident clinical or diagnostic changes have taken place. With age comes a degree of structural vascular changes that constitute healthy vascular aging, but this process can be diverted to its unsuccessful form, with prominent structural and functional alterations in the vasculature, resulting in poor arterial compliance and capacity to accommodate changes in blood pressure (BP).1 It has been determined that this diversion is most frequently associated with risk factors such as age, sex, race, family history, hypertension, diabetes mellitus, heart disease, serum lipid levels, central obesity, physical inactivity, alcohol abuse, and smoking.2–4 Deficiency of systematic vascular research in women,2,4 encouraged design of this study to assess the temporal outline of common carotid mechanics with vascular aging profile for women, using several biomarkers since they show a tendency for age-associated changes.2 One hundred clinically healthy women from Croatia aged 25 to 75, subdivided into five 10-year age groups, participated in the study. All participants provided informed consent previously approved by the hospital ethics committee. Exclusion criteria were any previously established vascular disease or evident early atherosclerotic changes (intima-media thickness (IMT) of the distal common carotid artery (CCA) wall >0.8 mm), but individuals with controlled hypertension (23.1%), high body mass index (BMI; 29.8%) and smokers (19.2%) were included. The mean of three noninvasive brachial blood pressure (BP) readings was used, and pulse pressure (PP) was calculated.2 Ultrasound measurements were performed on the distal CCA (1.5 cm proximal to the carotid bifurcation) using a 13-MHz linear
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transducer (5500-SSD Prosound, Aloka Co., Ltd., Tokyo, Japan) in B and M modes using standard protocols and recommendations.5 Evaluated carotid biomarkers were CCA IMT, systolic and diastolic carotid interadventitial diameter (CID) and the difference between the two (CIDc) as measures of arterial compliance while circumferential arterial strain (CAS) and beta stiffness index (BSI) were used as measures of carotid stiffness. CAS and BSI were calculated using standard formulas.6 Repeated-measure analysis of variance (ANOVA) was conducted on BSI, BP, and BMI across age groups after the Kolmogorov-Smirnov and BartelletovBox tests confirmed that the sample was significantly nonnormal (P = .95). Multiple regression analysis and nonlinear regression modeling were conducted using Curve Expert 1.3 (http://softadvice.informer.com/Curve_Expert_1. 3_Download.html). Statistical significance was verified using the F-test (a=0.05, F0 = 10.13). Average BP was 121.9 11.4/76.8 6.7 mmHg (24% of women were hypertensive), average PP was 45.0 7.1 mmHg, average BMI was 25.2 4.0 kg/m2, 29.8% of women were overweight (>25.0 kg/m2), and 12.5% were obese (>30.0 kg/m2). Twenty women (20%) were active smokers (average 16.8 pack-years), and 64% were never smokers. CID was uniform bilaterally (range 6.50–7.05 mm, right; 6.20–6.78 mm, left). Figure 1 shows detailed descriptive data for IMT, CIDc, CAS, and BSI bilaterally across age groups, with significant side-to-side difference. Multivariate regression analysis showed no association between BSI, BP, or BMI and investigated parameters across age groups (ANOVA, F(3.16) = 0.19, P = .65), as previously reported.7 The current study confirmed a strong correlation between IMT and age (correlation coefficient (r) = 0.994, S = 0.012, F = 122.74), with an average 0.0021 0.0003 mm/year increase. A strong linear correlation was also found between BSI and age (r = 0.986, S = 0.479, F = 51.34), with an average yearly increase of 8.5 0.4. This is the first report of a strong linear relationship between muscular artery stiffness and age in women. Until now, it has been reported that stiffness increases proportionally with age only in large elastic arteries.8 Furthermore, another novel and intriguing result of this study is that modeling of CIDc and CAS data showed behavior easily approximated using the piecewise linear function with three slopes (Figure 1); coefficients were equal bilaterally for both CAS (b = 0.002) and CIDc (b = 0.009). A value plateau is observed between the ages of 40 and 60 (b = 0), after which a sharp decrease in CAS and CIDc was noted again (Figure 1), suggesting the existence of temporal biological stability for CAS and CIDc, with no observed side-to-side difference. The data from the current study confirm the existence of arterial remodeling due to an increase in PP that alters intrinsic CCA viscoelastic properties. Such changes were previously established as early indicators of vascular damage and vascular event prediction.8,9 Additionally, change of 1 standard deviation for CIDc and BSI indicate a 15% greater risk of hypertension development (Atherosclerosis Risk in Communities prospective study).10 The ultrasoundbased modeling in women of the current study suggests that a temporal window between the ages of 40 and 60 is the optimal time to begin preventive and protective cerebrovascular strategies during which carotid strain and
LETTERS TO THE EDITOR
compression suit. Pressures generated from the different methods varied from 15 to 60 mmHg, where reported. The various outcome measures used are detailed in Table 1. When symptoms were reported, they were assessed using unvalidated methods. All studies assessed orthostatic BP response in a single observation, with Study A also assessing symptoms after 1 month of use of compression bandages. Of the three studies that assessed symptoms (A, B, D), two reported a statistically significant reduction in symptoms during testing with compression bandages, and the other reported increasing improvement in symptoms with different levels of external compression. Of the two studies that used the lying-to-sitting method, one found a decrease in the prevalence of OH with compression, whereas the other did not. Study B did not report change in BP, the other four all reported a significant reduction in the BP drop or a significant increase in BP with compression. Study A, which reported symptoms after 1 month of lower limb compression, found a significant reduction in symptoms and an adherence rate of 71%. Although the aim was to perform a systematic review and meta-analysis of the use of lower limb compression in the treatment of OH, it was not possible because of the quantity and quality of the studies available. The focus of the studies was observational, using compression during a single orthostatic challenge. Only one study assessed the effects beyond a single episode, but this was not controlled, randomized or blinded. Although these studies were small and had significant weaknesses, they provide a small degree of support for the use of lower limb compression, although the evidence is weak and is more supportive of investigating their use further than of a clinical intervention. Lower limb and abdominal compression is arguably not a simple intervention. It is time consuming and difficult to fit, and many older people would struggle to use the necessary devices. If such measures are to be recommended for older people in the treatment of OH, these recommendations should be based on good evidence. A clinical trial of the use of compression to treat OH would be timely now; the prevalence of OH is increasing, and the results would be far reaching. James Frith, PhD Julia L. Newton, PhD Biomedical Research Centre in Ageing and Age Related Diseases, National Institute for Health Research, Institute for Ageing and Health, Newcastle University, Newcastle, UK
ACKNOWLEDGMENTS Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: Frith: concept and design, independent article review, principle author. Newton: independent article review, author contributor. Sponsor’s Role: None.
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REFERENCES 1. Shiboa C. Orthostatic hypotension related hospital admissions in the United States. Am J Med 1990;113:308–316. 2. Lahrmann H, Cortelli P, Hilz M et al. EFNS guidelines on the diagnosis and management of orthostatic hypotension. Eur J Neurol 2006;13:930– 936. 3. Podoleanu C, Maggi R, Brignole M et al. Lower limb and abdominal compression bandages prevent progressive orthostatic hypotension in elderly persons: A randomized single-blind controlled study. J Am Coll Cardiol 2006;48:1425–1432. 4. Gorelik O, Fishlev G, Almoznino-Sarafian D et al. Lower limb compression bandaging is effective in preventing signs and symptoms of seating-induced postural hypotension. Cardiology 2004;102:177–183. 5. Smit AA, Wieling W, Fujimura J et al. Use of lower abdominal compression to combat orthostatic hypotension in patients with autonomic dysfunction. Clin Auton Res 2004;14:167–175. 6. Denq JC, Opfer-Gehrking TL, Giuliani M et al. Efficacy of compression of different capacitance beds in the amelioration of orthostatic hypotension. Clin Auton Res 1997;7:321–326. 7. Gorelik O, Almoznino-Sarafian D, Litvinov V et al. Seating-induced postural hypotension is common in older patients with decompensated heart failure and may be prevented by lower limb compression bandaging. Clin Auton Res 2009;55:138–144.
AVOIDING EMERGENCY DEPARTMENT ADMISSIONS USING TELEPHONIC CONSULTATIONS BETWEEN GENERAL PRACTITIONERS AND HOSPITAL GERIATRICIANS To the Editor: Elderly people are four times as likely to be hospitalized as younger age groups and may occupy hospital beds for longer periods of time.1 Individuals aged 75 and older are frequently hospitalized, often in an unplanned way, which leads to longer hospital stays and iatrogenic complications, especially functional decline.2 Numerous studies and meta-analyses have tried to determine how to decrease emergency department (ED) admissions and readmissions for older adults.3–8 Most have found that better hospital discharge organization significantly reduces the risk of early readmission (within 30 days) (discharge planning and short, structured, discharge summaries accessible over the Internet). The literature also shows that improving communications with community care physicians may enhance care, and reduce the rate of ED admissions and early readmissions. The aim of this study was to evaluate the effect of a telephone hotline in assisting general practitioners in their decisionmaking to improve and smooth the transition of older adults to the hospital.
METHODS Representatives of the Regional Union of General Practitioners of the southwest of France (Aquitaine) and the Department of Geriatrics and the administration of the University Hospital of Bordeaux set up this experiment in November 2010. The goals of this hotline were to meet the expectations of general practitioners by allowing a direct call with a geriatrician every day, Monday to Friday (9 a.m.–7 p.m.) and to give medical advice and alternatives to ED admissions (planned geriatric consultations, day hospital, or geriatric medicine hospitalizations). The telephone switchboard of the University Hospital of
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APRIL 2014–VOL. 62, NO. 4
LETTERS TO THE EDITOR
783
Table 1. Solutions Given to General Practitioners According to the Reasons for the Hotline Calls (N = 228)
Characteristic
Age, mean SD Living alone, n (%) Living in a nursing home, n (%) Behavioral disorder, n (%) Unexplained asthenia, n (%) Social problems, n (%) Repeated falls, n (%)
Medical Advice, n = 87
86.5 7.5 19 (23.5) 30 (53.6) 31 13 8 4
(46.9) (34.2) (34.8) (13.8)
Consultation or Hospital Day, n = 33
85.2 4.8 15 (18.5) 4 (7.1) 9 4 8 7
(13.6) (10.5) (34.8) (24.1)
Planned Hospitalization, n = 98
86.6 5.3 45 (55.6) 19 (3.4) 26 21 7 17
(39.4) (55.3) (30.4) (58.6)
Emergency Department Admission, n = 10
P-Value
85.0 7.3 2 (2.5) 3 (5.4)
.52 .002 .04
0 0 0 1
(0.0) (0.0) (0.0) (3.4)
.15 .03 .02 .003
Bordeaux routinely quantified all telephone calls. All of the geriatricians in charge of this hotline recorded data regarding the reasons for calls, solutions proposed to general practitioners, and patient characteristics, including sociodemographic data, level of autonomy, comorbidities, and medical problems. All of the general practitioners were asked how they would have handled each situation if the hotline had not been available (e.g., emergency admission). Statistical analyses were performed using SPSS 11.5 (SPSS Inc., Chicago, IL). Continuous variables were compared using t-tests, dichotomous variables using chisquare tests, and multiple comparisons using analysis of variance.
hotline might be a good tool for improving integrated care of older adults.
RESULTS
Virginie Valentin, Direction of the University Hospital of Bordeaux, Talence, France
Seven hundred fourteen calls were recorded from November 2010 to February 2012 for the management of 230 older adults (mean age 86.2 6.2). Most of the individuals included lived at home (70.7%), and 60% of these lived alone. The calls were mostly about the management of behavioral disorders (29.5%), unexplained asthenia (17%), repeated falls (13%), treatment of acute diseases such as cardiac insufficiency or infection (12.5%), and complex social problems (10.3%). Only 4.3% of individuals were directly admitted to the ED, and the hotline permitted the avoidance of ED admissions in 81.4% of cases. The responses of the geriatricians in charge of this hotline were to give medical advice to the general practitioners (38.3%) or to schedule a geriatric consultation (5.3%), a day hospital visit (9.2%), or hospitalization in a geriatrics ward (42.9%). As shown in Table 1, a planned hospitalization in a geriatric ward was an alternative to ED admission for individuals with repeated falls, unexplained asthenia, or living alone. Only a few studies have reported results on the efficacy of such a hotline for general practitioners. Data have mainly focused on gaps in continuity of care at the interface between primary care and specialized care after hospitalization. Nevertheless, alternative models of care are reported, including primary prevention programs, programs of care including self-management and pharmaceutical programs, and prehospital comprehensive geriatric assessment.8 In conclusion, this hotline allowed prompt answers to general practitioners’ questions, improved and streamlined the transition of older adults to the hospital, and assisted general practitioners in their decisions. This
Nathalie Salles, MD, PhD Marie Floccia, MD Marie-Neige Videau, MD Leila Diallo, MD P^ ole de Gerontologie Clinique, H^ opital Xavier-Arnozan, Centre Hospitalier Universitaire de Bordeaux, Pessac, France Dany Guerin, MD Regional Union of General Practitioners Aquitaine, Bordeaux, France
Muriel Rainfray, MD, PhD P^ ole de Gerontologie Clinique, H^ opital Xavier-Arnozan, Centre Hospitalier Universitaire de Bordeaux, Pessac, France
ACKNOWLEDGMENTS N. Salles, L. Diallo, M. N. Videau, M. Floccia, M. Rainfray. Does a hotline for General Practitioners improve the care of older frail patients? A pilot study. 9th Congress of the EUGMS, Venice, Italy, October 2013. N Salles, L Diallo, MN Videau, M Floccia, J Charrieau, M Rainfray. Does a hotline for General Practitioners improve the care of older frail patients? A pilot study. 20th IAGG World Congress of Gerontology and Geriatrics, Seoul, Korea, June 2013. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: All authors: design and interpretation. Salles: statistical analysis, interpretation of data, writing the paper. Floccia, Videau, Diallo: data collection. Guerin, Valentin, Rainfray: study conception. Sponsor’s Role: No commercial company sponsored or played any role in the design, methods, subject recruitment, data collection, analysis, or preparation of this letter.
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LETTERS TO THE EDITOR
REFERENCES 1. Wallace E, Hinchey T, Dimitrov BD et al. A systematic review of the probability of repeated admission score in community-dwelling adults. J Am Geriatr Soc 2013;61:357–364. 2. Graf C. Functional decline in hospitalized older adults. Am J Nurs 2006;106:58–67, quiz 67–58. 3. Allen J, Ottmann G, Roberts G. Multi-professional communication for older people in transitional care: A review of the literature. Int J Older People Nurs 2013;8:253–269. 4. Bunn F, Byrne G, Kendall S. Telephone consultation and triage: Effects on health care use and patient satisfaction. Cochrane Database Syst Rev 2004; Issue 3. Art. No:CD004180. doi: 10.1002/14651858.CD004180.pub2 5. Hesselink G, Schoonhoven L, Barach P et al. Improving patient handovers from hospital to primary care: A systematic review. Ann Intern Med 2012;157:417–428. 6. Parker SG, Peet SM, McPherson A et al. A systematic review of discharge arrangements for older people. Health Technol Assess 2002;6:1–183. 7. Rennke S, Nguyen OK, Shoeb MH et al. Hospital-initiated transitional care interventions as a patient safety strategy: A systematic review. Ann Intern Med 2013;158:433–440. 8. Shepperd S, Lannin NA, Clemson LM et al. Discharge planning from hospital to home. Cochrane Database Syst Rev 2013;Issue 1. Art. No.: CD000313. doi: 10.1002/14651858.CD000313.pub4
ARTERIAL COMPLIANCE PLATEAUS IN HEALTHY AGING WOMEN—IN TIME FOR PREVENTIVE TREATMENT To the Editor: The increasing prevalence of cardiovascular diseases with advancing age is placing a growing burden on society and healthcare systems worldwide, making it crucial to identify the optimal time for effective prevention, before evident clinical or diagnostic changes have taken place. With age comes a degree of structural vascular changes that constitute healthy vascular aging, but this process can be diverted to its unsuccessful form, with prominent structural and functional alterations in the vasculature, resulting in poor arterial compliance and capacity to accommodate changes in blood pressure (BP).1 It has been determined that this diversion is most frequently associated with risk factors such as age, sex, race, family history, hypertension, diabetes mellitus, heart disease, serum lipid levels, central obesity, physical inactivity, alcohol abuse, and smoking.2–4 Deficiency of systematic vascular research in women,2,4 encouraged design of this study to assess the temporal outline of common carotid mechanics with vascular aging profile for women, using several biomarkers since they show a tendency for age-associated changes.2 One hundred clinically healthy women from Croatia aged 25 to 75, subdivided into five 10-year age groups, participated in the study. All participants provided informed consent previously approved by the hospital ethics committee. Exclusion criteria were any previously established vascular disease or evident early atherosclerotic changes (intima-media thickness (IMT) of the distal common carotid artery (CCA) wall >0.8 mm), but individuals with controlled hypertension (23.1%), high body mass index (BMI; 29.8%) and smokers (19.2%) were included. The mean of three noninvasive brachial blood pressure (BP) readings was used, and pulse pressure (PP) was calculated.2 Ultrasound measurements were performed on the distal CCA (1.5 cm proximal to the carotid bifurcation) using a 13-MHz linear
APRIL 2014–VOL. 62, NO. 4
JAGS
transducer (5500-SSD Prosound, Aloka Co., Ltd., Tokyo, Japan) in B and M modes using standard protocols and recommendations.5 Evaluated carotid biomarkers were CCA IMT, systolic and diastolic carotid interadventitial diameter (CID) and the difference between the two (CIDc) as measures of arterial compliance while circumferential arterial strain (CAS) and beta stiffness index (BSI) were used as measures of carotid stiffness. CAS and BSI were calculated using standard formulas.6 Repeated-measure analysis of variance (ANOVA) was conducted on BSI, BP, and BMI across age groups after the Kolmogorov-Smirnov and BartelletovBox tests confirmed that the sample was significantly nonnormal (P = .95). Multiple regression analysis and nonlinear regression modeling were conducted using Curve Expert 1.3 (http://softadvice.informer.com/Curve_Expert_1. 3_Download.html). Statistical significance was verified using the F-test (a=0.05, F0 = 10.13). Average BP was 121.9 11.4/76.8 6.7 mmHg (24% of women were hypertensive), average PP was 45.0 7.1 mmHg, average BMI was 25.2 4.0 kg/m2, 29.8% of women were overweight (>25.0 kg/m2), and 12.5% were obese (>30.0 kg/m2). Twenty women (20%) were active smokers (average 16.8 pack-years), and 64% were never smokers. CID was uniform bilaterally (range 6.50–7.05 mm, right; 6.20–6.78 mm, left). Figure 1 shows detailed descriptive data for IMT, CIDc, CAS, and BSI bilaterally across age groups, with significant side-to-side difference. Multivariate regression analysis showed no association between BSI, BP, or BMI and investigated parameters across age groups (ANOVA, F(3.16) = 0.19, P = .65), as previously reported.7 The current study confirmed a strong correlation between IMT and age (correlation coefficient (r) = 0.994, S = 0.012, F = 122.74), with an average 0.0021 0.0003 mm/year increase. A strong linear correlation was also found between BSI and age (r = 0.986, S = 0.479, F = 51.34), with an average yearly increase of 8.5 0.4. This is the first report of a strong linear relationship between muscular artery stiffness and age in women. Until now, it has been reported that stiffness increases proportionally with age only in large elastic arteries.8 Furthermore, another novel and intriguing result of this study is that modeling of CIDc and CAS data showed behavior easily approximated using the piecewise linear function with three slopes (Figure 1); coefficients were equal bilaterally for both CAS (b = 0.002) and CIDc (b = 0.009). A value plateau is observed between the ages of 40 and 60 (b = 0), after which a sharp decrease in CAS and CIDc was noted again (Figure 1), suggesting the existence of temporal biological stability for CAS and CIDc, with no observed side-to-side difference. The data from the current study confirm the existence of arterial remodeling due to an increase in PP that alters intrinsic CCA viscoelastic properties. Such changes were previously established as early indicators of vascular damage and vascular event prediction.8,9 Additionally, change of 1 standard deviation for CIDc and BSI indicate a 15% greater risk of hypertension development (Atherosclerosis Risk in Communities prospective study).10 The ultrasoundbased modeling in women of the current study suggests that a temporal window between the ages of 40 and 60 is the optimal time to begin preventive and protective cerebrovascular strategies during which carotid strain and
