Editor’s view: tackling geriatric giants

New horizons in peripheral artery disease

Peripheral artery disease (PAD) is a common condition among older adults, especially those over 65 in high-income countries, where it affects more than 10% of this age group. Prevalence of frailty, cognitive impairment and multimorbidity, accompanied by polypharmacy, is high in this population. As depicted in the New Horizons paper of Haughton et al. [1], UK guidelines emphasise the importance of involving specialist geriatric teams in the care of older PAD patients, particularly those undergoing surgery. This support helps manage the unique needs of these patients during the perioperative period, enhancing their overall treatment and recovery. In recent years, there have been significant innovations in the medical and surgical management of PAD, revolutionising treatment options, as described in their New Horizons paper. Awareness of PAD and the importance of early referral for patients with critical limb-threatening ischemia is crucial. Newer, minimally invasive technologies now make it possible to treat even older, frailer patients with complex disease conditions.

A good death

For patients nearing the end of life, the harms of curative and preventive treatments often outweigh their benefits. Most older adults in Western societies prefer to die at home rather than in hospitals, yet the majority of deaths still occur in hospital settings.

Clinicians face challenges in withdrawing curative care due to their strong training in life-saving measures, prognostic uncertainty, lack of end-of-life care training, time constraints, legal concerns and conflicting wishes between patients and their families. This can lead to non-beneficial treatments being administered at the end of life.

In the InterACT Stepped Wedge Trial, White et al. [2] assessed whether a nudge intervention could improve patient management. Their findings showed that this approach alone was insufficient to reduce non-beneficial treatment outcomes in older hospital patients. They suggest that more direct interventions and policy changes are needed to effectively minimise non-beneficial treatments at the end of life.

Accelerated biological ageing

Epigenetic age, also known as the epigenetic clock or DNA methylation-derived biological age, is an emerging biomarker of ageing. When an individual’s epigenetic age exceeds their chronological age, it is termed epigenetic age acceleration (AA). AA has been linked to many age-related diseases, sparking interest in its potential to predict deterioration across various biological and physiological systems.

In a longitudinal cohort study of 570 older Australian adults, Phyo et al. [3] examined the association between epigenetic AA and physical/physiological decline, specifically frailty and disability in activities of daily living (ADL). They found that epigenetic AA was associated with increasing frailty scores each year and a higher risk of developing frailty as defined by a frailty index (FI). They concluded that epigenetic AA could serve as a predictor of future frailty, even in initially healthy older individuals.

Tackling incontinence

Many people struggle with continence issues at home without seeking help due to embarrassment, believing it is a normal part of ageing, and being unaware of treatment options. Pharmacological solutions can help manage certain types of incontinence, such as prostate problems, nocturia or overactive bladder. However, the risks of polypharmacy in older adults, particularly those who are housebound and frail, and the long-term side effects of anticholinergic medications make alternative approaches necessary.

Evidence suggests that incontinence can be managed for many people using simple lifestyle and behavioural changes. Most research on incontinence in older adults has focused on hospital or care home settings, where prevalence is easier to estimate, and intervention effects are more readily quantified. To address this gap, Buck et al. [4] conducted a systematic review to evaluate the effectiveness of home-delivered interventions for urinary and/or faecal incontinence in community-living older adults. They found limited but robust evidence supporting conservative in-home interventions for urinary incontinence. However, randomised controlled trials for managing faecal incontinence in this population and setting are lacking.

Osteoporosis in the oldest-old, a missed opportunity?

In a retrospective cohort study of 175 in-hospital hip fracture patients aged 95 and over, Barceló et al. [5] evaluated the advisability of initiating osteoporosis treatment post-hip fracture by examining new fragility fractures, mortality risk factors and long-term survival. As the number of centenarians and near-centenarians rises, particularly in Western societies, falls and osteoporosis—major risk factors for hip fractures—become more prevalent with age.

Current clinical guidelines do not restrict the age for starting osteoporosis treatment or the time to benefit (6–24 months), which aligns with the life expectancy of the majority of older hip fracture patients. Despite the proven effectiveness of osteoporosis drugs in preventing new fractures and the lack of age-related adverse effects, many patients, particularly those over 80, do not receive these treatments.

Barceló et al. found that 5.7% of these exceptionally long-lived patients experienced new fragility fractures within 3.2 years post-discharge, with half occurring in the first few months—an identified period of maximum risk. Notably, most of these patients were not on osteoporosis treatment. Given the low prevalence and the short time to refracture, they thus could not conclude that this was a missed opportunity. However, this does highlight the critical need for implementing a multifactorial fall risk assessment and corresponding treatment as standard care for older hip fracture patients.

Diagnosing Alzheimer’s disease: a new EEG-based index

Over the past decades, several biomarkers have been identified for diagnosing Alzheimer’s disease (AD). Vecchio et al. [6] now introduce a promising new index aimed at uncovering specific brain connectivity patterns associated with AD, defined according to neuropsychological patterns. They explored the Electroencephalographic (EEG) Small World (SW) organisation in brain networks to gain insights into neurodegeneration in AD.

The study involved EEG recordings of 370 people, including 170 healthy subjects and 200 mild-AD patients, acquired across different clinical centres with harmonised acquisition settings. The objective was to create a unified index that effectively distinguishes individuals with ad-compatible neuropsychological patterns from healthy individuals. The index demonstrated a high discriminative capability, validated through support vector machine (SVM) analysis, achieving an accuracy of 87%, a sensitivity of 95.5%, a specificity of 77% and an AUC of 0.939.

The study concludes that this novel index could represent a significant step towards identifying reliable biomarkers for the early diagnosis of AD, enabling timely and personalised interventions and distinguishing AD from other forms of dementia and healthy ageing.

The damage of inappropriate polypharmacy

Polypharmacy can be an appropriate response to managing multiple health conditions, yet it poses risks when medications are unnecessary or cause harm in older adults. These risks include increased hospitalizations, adverse drug reactions (ADRs) and prescribing cascades—where new medications are prescribed to address ADRs from existing ones, intentionally or unintentionally. Jennings et al. [7] conducted a qualitative study aiming to understand stakeholder perceptions and attitudes towards problematic polypharmacy, with a focus on prescribing cascades. Through one-to-one semi-structured interviews in Ireland, stakeholders highlighted the delicate balance required when managing multimorbidity with multiple medications.

Stakeholders acknowledged that ADRs and prescribing cascades are often unavoidable in older patients with multimorbidity. Clinicians emphasised the challenge of balancing risks and benefits for each patient, integrating evidence, clinical experience and patient preferences. Furthermore, they identified transitions of care, particularly following hospital discharge, as high-risk periods for medication-related issues, underscoring the need for improved medicines reconciliation processes.

In their editorial, Hernandez-Palacios et al. [8] highlight another pressing concern of inappropriate polypharmacy. The escalating consumption of pharmaceuticals due to ageing populations and technological advancements in treating chronic diseases does not only strains healthcare systems but also contributes significantly to carbon emissions, with medicines estimated to constitute 25% of NHS emissions.

Medication reviews play a crucial role in optimising patient outcomes and reducing healthcare costs. Addressing inappropriate polypharmacy in older adults not only enhances their quality of life but also mitigates the environmental impact of medications. This dual benefit aligns with global health initiatives, such as the Third Global Patient Safety Challenge, Medication Without Harm, aiming to reduce medication-related harm and improve patient safety worldwide.

Deputy Editor, Age and Ageing journal

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