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Blood pressure lowering therapy in older people: Does it really cause postural hypotension or falls?

Zia A, Kamaruzzaman SB, Tan MP

Postgrad Med, 2015 Mar;127(2):186-93.
PMID: 25622817 DOI: 10.1080/00325481.2015.996505

Hypertension is a highly prevalent condition among older people, but many physicians avoid aggressive treatment in this age group due to concerns about adverse effects such as orthostatic hypotension and falls. Orthostatic hypotension, which also increases in prevalence with increasing age, has been considered to be associated with antihypertensive therapy. Both orthostatic hypotension and antihypertensive medications are considered independent yet closely related predictors for falls among older people. The prescription of antihypertensive therapy among the elderly remains a long-standing controversy in geriatric medicine due to ongoing concerns about potential complications such as falls, despite conclusive evidence supporting the treatment of hypertension even among the very elderly. However, recent evidence suggests a dose-dependent relationship between blood pressure lowering therapy and falls among older individuals with preexisting risk factors for falls. In response to the spate of revisions in hypertension treatment targets for older patients in international guidelines and the recent evidence on antihypertensive therapy and falls, this review article examines the complex relationship between hypertension, antihypertensives, orthostatic hypotension, and falls among older patients.
Polypharmacy and falls in older people: Balancing evidence-based medicine against falls risk

Zia A, Kamaruzzaman SB, Tan MP

Postgrad Med, 2015 Apr;127(3):330-7.
PMID: 25539567 DOI: 10.1080/00325481.2014.996112

The term polypharmacy has negative connotations due to its association with adverse drug reactions and falls. This spectrum of adverse events widens when polypharmacy occurs among the already vulnerable geriatric population. To date, there is no consensus definition of polypharmacy, and diverse definitions have been used by various researchers, the most common being the consumption of multiple number of medications. Taking multiple medications is considered a risk factor for falls through the adverse effects of drug-drug or drug-disease interactions. Falls studies have determined that taking ≥ 4 drugs is associated with an increased incidence of falls, recurrent falls, and injurious falls. In light of existing evidence, careful and regular medication reviews are advised to reduce the effect of polypharmacy on falls. However, intervention studies on medication reviews and their effectiveness on falls reduction have been scarce. This article reviews and discusses the evidence behind polypharmacy and its association with falls among older individuals, and highlights important areas for future research.
Falls, frailty, and metabolic syndrome in urban dwellers aged 55 years and over in the Malaysian elders longitudinal research (MELoR) study - a cross-sectional Study

Teoh RJJ, Mat S, Khor HM, Kamaruzzaman SB, Tan MP

Postgrad Med, 2021 Apr;133(3):351-356.
PMID: 33143493 DOI: 10.1080/00325481.2020.1842026

OBJECTIVES: While metabolic syndrome, falls, and frailty are common health issues among older adults which are likely to be related, the potential interplay between these three conditions has not previously been investigated. We investigated the relationship between metabolic syndrome with falls, and the role of frailty markers in this potential relationship, among community-dwelling older adults.
METHODS: Data from the first wave Malaysian Elders Longitudinal Research (MELoR) study comprising urban dwellers aged 55 years and above were utilized. Twelve-month fall histories were established during home-based, computer-assisted interviews which physical performance, anthropometric and laboratory measures were obtained during a hospital-based health check. Gait speed, exhaustion, weakness, and weight loss were employed as frailty markers.
RESULTS: Data were available for 1415 participants, mean age of 68.56 ± 7.26 years, 57.2% women. Falls and metabolic syndrome were present in 22.8% and 44.2%, respectively. After adjusting for age, sex, and multiple comorbidities, metabolic syndrome was significantly associated with falls in the sample population [odds ratio (OR): 1.33, 95% confidence interval (CI): 1.03; 1.72]. This relationship was attenuated by the presence of slow gait speed, but not exhaustion, weakness, or weight loss.
CONCLUSION: Metabolic syndrome was independently associated with falls among older adults, and this relationship was accounted for by the presence of slow gait speed. Future studies should determine the value of screening for frailty and falls with gait speed in older adults with metabolic syndrome as a potential fall prevention measure.
Defining metabolic syndrome and factors associated with metabolic syndrome in a poly-pharmaceutical population

McStea M, McGeechan K, Kamaruzzaman SB, Rajasuriar R, Tan MP

Postgrad Med, 2016 Nov;128(8):797-804.
PMID: 27558757 DOI: 10.1080/00325481.2016.1229103

Metabolic Syndrome (METs) definitions vary and diagnosis takes into account consumption of medications commonly prescribed for conditions defining METs. This paper evaluates the potential differences in population characteristics using two different methods of defining METs, with and without the adjustment of the effects of pharmacotherapy on biochemical and blood pressure (BP) measurements Methods: This was a cross-sectional study utilizing the Malaysian Elders Longitudinal Research (MELoR) cohort comprising urban community-dwellers aged ≥55 years. Participants were interviewed using a structured questionnaire during home visits where medications were reviewed. Health impacts assessed included heart disease, stroke, body mass index (BMI), peptic ulcers, arthritis, and number of medications and comorbidities. Risk factors and health impacts associated with METs were determined by Poisson multivariate regression models using a binary and count dependent variables.
An unexpected cause of transient diarrhea

Chuah YY, Lee YY, Tsai TJ

Postgrad Med, 2017 May;129(4):488-490.
PMID: 28335674 DOI: 10.1080/00325481.2017.1311198

Migration of percutaneous endoscopic gastrostomy (PEG) tube to colon with gastro-colonic-cutaneous fistula formation is a rare complication of the procedure. Transient episodic diarrhea following each PEG tube feeding is typical of this complication. We present a 72-year-old man with cerebrovascular disease and scoliosis who encountered episodes of transient diarrhea after each PEG tube feeding. His diarrhea was refractory to medications. Colonoscopy demonstrated a mal-positioned PEG in the transverse colon. Computed tomogram (CT) of abdomen further confirmed the finding. After removal of the migrated PEG, his diarrhea had ceased completely. The gastro-colonic-cutaneous fistula was further managed with endoscopic clipping method with no complications encountered during follow up.
The effect of physical activity, body mass index and waist circumference on incident diabetes

Mahakkanukrauh P, Sinthubua A, Das S

Postgrad Med, 2018 03;130(2):186.
PMID: 29115878 DOI: 10.1080/00325481.2018.1402657
A review on the performance of osteoporosis self-assessment tool for Asians in determining osteoporosis and fracture risk

Chin KY

Postgrad Med, 2017 Sep;129(7):734-746.
PMID: 28695762 DOI: 10.1080/00325481.2017.1353394

The prevalence of osteoporosis in Asian countries is growing. An effective screening method will enable patients at risk for osteoporosis to receive early diagnosis and treatment, and avoid overcrowding the limited dual-energy x-ray absorptiometry (DXA) machines available in Asian countries. Many simple osteoporosis screening algorithms have been developed but they are not validated for use in Asian populations. osteoporosis self-assessment tools for Asians (OSTA), established using a multinational Asian cohort, is the first screening algorithm that caters for the Asian populations. It considers only body weight and age in the algorithm. It shows consistently high performance and sensitivity in identifying postmenopausal women at risk for osteoporosis in many Asian countries. Its usage has been expanded for identifying osteoporosis in men, as well as determining fracture risk for both sexes. However, the performance of OSTA is influenced by age, sex, ethnicity and site of BMD measurement to define osteoporosis. Its usage is also limited in individuals without apparent risk factors. These limitations should be noted by physicians considering the use of OSTA in clinical setting. As a conclusion, OSTA is a cost-effective measure for osteoporosis screening in primary healthcare setting.
Acceptance of virtual consultations among older adults and caregivers in Malaysia: a pilot study during the COVID-19 pandemic

Tan YR, Tan MP, Khor MM, Hoh HB, Saedon N, Hasmukharay K, et al.

Postgrad Med, 2022 Mar;134(2):224-229.
PMID: 34758702 DOI: 10.1080/00325481.2021.2004792

AIM: The COVID-19 pandemic has disrupted the delivery of healthcare to vulnerable older adults, prompting the expansion of telemedicine usage. This study surveyed the acceptance of virtual medical consultations among older adults and caregivers within geriatric outpatient services in a tertiary hospital during the pandemic.
METHODS: A cross-sectional survey was conducted among caregivers and patients attending geriatric outpatient services in Kuala Lumpur, Malaysia. The survey measured the availability of equipment for virtual consultations, prior knowledge and experience of telemedicine, and willingness to consult geriatricians through virtual technology, using the Unified Theory of Acceptance and Use of Technology (UTAUT) scale.
RESULTS: A total of 197 caregivers and 42 older patients with a mean age of 54.28 (±13.22) and 75.62 (±7.32) years, respectively, completed the survey. One hundred and fifty-six (79.2%) of the caregivers were adult children accompanying patients. The mean UTAUT score was 65.97 (±13.71) out of 90, with 66.64 (±13.25) for caregivers and 62.79 (±15.44) for older adults, suggesting a high acceptance of adopting virtual consultations in lieu of face-to-face care. The independent predictors of acceptance of virtual consultation were : possession of an electronic device capable of video-communication, living with someone, living in a care home, weekly online banking usage, and perceived familiarity with virtual platforms.
CONCLUSION: Caregivers and patients indicated a high level of acceptance of virtual medical consultations, which is likely facilitated by caregivers such as adult children or spouses at home or staff in care homes. To minimize the transmission of COVID-19 in a highly vulnerable group, virtual consultations are an acceptable alternative to face-to-face consultations for older people and their caregivers in our setting.
Predictors of stroke-associated pneumonia and the predictive value of neutrophil percentage-to-albumin ratio

Zawiah M, Khan AH, Abu Farha R, Usman A, AbuHammour K, Abdeen M, et al.

Postgrad Med, 2023 Sep;135(7):681-689.
PMID: 37756038 DOI: 10.1080/00325481.2023.2261354

BACKGROUND: Early recognition of stroke-associated pneumonia (SAP) is critical to reducing morbidity and mortality associated with SAP. This study investigated the predictors of SAP, and the predictive value of the neutrophil percentage-to-albumin ratio (NPAR) for SAP.
METHODS: This retrospective cohort study was conducted among stroke patients admitted to Jordan University Hospital from January 2015 to May 2021. Multivariable logistic regression was used to identify independent predictors for SAP. The predictive performance was assessed using C-statistics, described as the area under the receiver-operating characteristic curve (AUC, ROC) with a 95% confidence interval.
RESULTS: Four hundred and six patients were included in the analysis, and the prevalence of SAP was 19.7%. Multivariable logistic analysis showed that males (Adjusted Odds Ratio (AOR): 5.74; 95% Confidence Interval (95%CI): 2.04-1 6.1)], dysphagia (AOR: 5.29; 95% CI: 1.80-15.5), hemiparesis (AOR: 3.27; 95% CI: 1.13-9.47), lower GCS score (AOR: 0.73; 95% CI: 0.58-0.91), higher levels of neutrophil-lymphocyte ratio (NLR) (AOR: 1.15; 95% CI: 1.07-1.24), monocyte-lymphocyte ratio (MLR) (AOR: 1.49; 95% CI: 1.13-1.96), and neutrophil percentage to albumin ratio (NPAR) (AOR: 1.53; 95% CI: 1.33-1.76) were independent predictors of SAP. The NPAR demonstrated a significantly higher AUC than both the NLR (0.939 versus 0.865, Z = 3.169, p = 0.002) and MLR (0.939 versus 0.842, Z = 3.940, p
Fulltext Therapeutic role of immunomodulators during the COVID-19 pandemic- a narrative review

Al-Hajeri H, Baroun F, Abutiban F, Al-Mutairi M, Ali Y, Alawadhi A, et al.

Postgrad Med, 2022 Mar;134(2):160-179.
PMID: 35086413 DOI: 10.1080/00325481.2022.2033563

The emergency state caused by COVID-19 saw the use of immunomodulators despite the absence of robust research. To date, the results of relatively few randomized controlled trials have been published, and methodological approaches are riddled with bias and heterogeneity. Anti-SARS-CoV-2 antibodies, convalescent plasma and the JAK inhibitor baricitinib have gained Emergency Use Authorizations and tentative recommendations for their use in clinical practice alone or in combination with other therapies. Anti-SARS-CoV-2 antibodies are predominating the management of non-hospitalized patients, while the inpatient setting is seeing the use of convalescent plasma, baricitinib, tofacitinib, tocilizumab, sarilumab, and corticosteroids, as applicable. Available clinical data also suggest the potential clinical benefit of the early administration of blood-derived products (e.g. convalescent plasma, non-SARS-CoV-2-specific immunoglobins) and the blockade of factors implicated in the hyperinflammatory state of severe COVID-19 (Interleukin 1 and 6; Janus Kinase). Immune therapies seem to have a protective effect and using immunomodulators alone or in combination with viral replication inhibitors and other treatment modalities might prevent progression into severe COVID-19 disease, cytokine storm and death. Future trials should address existing gaps and reshape the landscape of COVID-19 management.