High blood pressure(HBP) is a risk factor for dementia. Clinical trials show antihypertensive treatment in those ∼60-80 years lowers risk of incident dementia. 1 However, observational data 2 show differing patterns of benefit/risk for HBP and dementia in older age which may relate to the confounding influence of frailty. Frailty is a syndromal diagnosis that reflects a loss of resilience, and exacerbates expression of dementia pathology. 3,4 Since varying levels of frailty are present in clinical trial participants, we sought to examine its role as a potential moderator of the impact of antihypertensive treatment on incident dementia. Single-stage individual-participant-data meta-analysis. Data were merged from four landmark double-blind placebo-controlled trials of antihypertensive drugs with blinded adjudicated dementia endpoints. Frailty was assessed using a robust tool, the frailty index(FI) where scores range from 0.01 to 1.00. Frailty was modelled as a continuous and binary variable FI≤0.21 for none/mild frailty and FI>0.21 moderate-severe frailty 5 . A multilevel multinomial regression model was used to determine the impact of baseline frailty on the impact of antihypertensive treatment on incident dementia taking account of the competing risk of death, unadjusted and adjusted for age, sex, education. Data on dementia and frailty were available for 24122 participants (mean age 68.5(SD9.31)yr, female 44%) with a median follow up of 4.5 years. Baseline FI median score was FI 0.16 (interquartile interval 0.11-0.23). Adjusted analyses: There was no interaction between frailty (continuous) and antihypertensive treatment and incident dementia ( p  = 0.47). For those an F ≤.21 the odds ratio for the impact of antihypertensive treatment was of 0.88(0.72,1.07) compared to 0.85(0.65,1.10) for an FI>0.21. Unadjusted results were similar. Antihypertensive treatment is likely to reduce incident dementia in those aged∼60-80 across varying levels of frailty. However, since clinical trial populations are biassed towards less frail participants, there are limitations to the generalizability of these data to more severe frailty in the general population. Further analyses will allow the investigation of the frailty/antihypertensive/dementia relationship in more detail. These data have implications for treatment guidelines for cardiovascular prevention alongside approaches to the management of people at high-risk of dementia. 1. Eur Heart J 2022;43(48):4980–90 2. JAMA Intern Med;2022;182(2):142-52 3. Lancet Neurol;2018;18(2):17784 4. Nat Aging;2021;1:651–65 5. Lancet Health Longev;2023;2(2)e96-e104

Observational studies indicate U-shaped associations of blood pressure (BP) and incident dementia in older age, but randomised controlled trials of BP lowering treatment show mixed results on this outcome in hypertensive patients. We undertook a pooled individual participant data analysis of five seminal double-blind placebo-controlled randomised trials to better define the effects of BP lowering treatment for the prevention of dementia and cognitive decline. Multilevel logistic regression was used to evaluate the treatment effect on incident dementia. Effect modification was assessed for key population characteristics including age, baseline systolic BP, sex, and presence of prior stroke. Mediation analysis was used to quantify the contribution of trial medication and changes in systolic and diastolic BP on risk of dementia. The total sample included 28,008 individuals recruited from 20 countries. After a median follow-up of 4.3 years, there were 861 cases of incident dementia. Multilevel logistic regression reported an adjusted odds ratio 0.87 (95% confidence interval 0.75, 0.99) in favour of antihypertensive treatment reducing risk of incident dementia with a mean BP lowering of 10/4mmHg. Further multinomial regression taking account of death as a competing risk found similar results. There was no effect modification by age or sex. Mediation analysis confirmed the greater fall in BP in the actively treated group was associated with a greater reduction in dementia risk. Using data from double-blind placebo-controlled clinical trials, we provide evidence in the first single-stage individual participant meta-analysis to support benefits of antihypertensive treatment in late-mid and later life to lower the risk of dementia. Questions remain as to the potential for additional BP lowering in those with already well-controlled hypertension and of antihypertensive treatment commenced earlier in the life-course to reduce the long-term risk of dementia.

AIMS Observational studies indicate U-shaped associations of blood pressure (BP) and incident dementia in older age, but randomized controlled trials of BP-lowering treatment show mixed results on this outcome in hypertensive patients. A pooled individual participant data analysis of five seminal randomized double-blind placebo-controlled trials was undertaken to better define the effects of BP-lowering treatment for the prevention of dementia. METHODS AND RESULTS Multilevel logistic regression was used to evaluate the treatment effect on incident dementia. Effect modification was assessed for key population characteristics including age, baseline systolic BP, sex, and presence of prior stroke. Mediation analysis was used to quantify the contribution of trial medication and changes in systolic and diastolic BP on risk of dementia. The total sample included 28 008 individuals recruited from 20 countries. After a median follow-up of 4.3 years, there were 861 cases of incident dementia. Multilevel logistic regression reported an adjusted odds ratio 0.87 (95% confidence interval: 0.75, 0.99) in favour of antihypertensive treatment reducing risk of incident dementia with a mean BP lowering of 10/4 mmHg. Further multinomial regression taking account of death as a competing risk found similar results. There was no effect modification by age or sex. Mediation analysis confirmed the greater fall in BP in the actively treated group was associated with a greater reduction in dementia risk. CONCLUSION The first single-stage individual patient data meta-analysis from randomized double-blind placebo-controlled clinical trials provides evidence to support benefits of antihypertensive treatment in late-mid and later life to lower the risk of dementia. Questions remain as to the potential for additional BP lowering in those with already well-controlled hypertension and of antihypertensive treatment commenced earlier in the life-course to reduce the long-term risk of dementia. CLASSIFICATION OF EVIDENCE Class I evidence in favour of antihypertensive treatment reducing risk of incident dementia compared with placebo.

OBJECTIVE:High blood pressure is one of the main modifiable risk factors for dementia. However, there is conflicting evidence regarding the best antihypertensive class for optimizing cognition. Our objective was to determine whether any particular antihypertensive class was associated with a reduced risk of cognitive decline or dementia using comprehensive meta-analysis including reanalysis of original participant data.METHODS:To identify suitable studies, MEDLINE, Embase, and PsycINFO and preexisting study consortia were searched from inception to December 2017. Authors of prospective longitudinal human studies or trials of antihypertensives were contacted for data sharing and collaboration. Outcome measures were incident dementia or incident cognitive decline (classified using the reliable change index method). Data were separated into mid and late-life (>65 years) and each antihypertensive class was compared to no treatment and to treatment with other antihypertensives. Meta-analysis was used to synthesize data.RESULTS:Over 50,000 participants from 27 studies were included. Among those aged >65 years, with the exception of diuretics, we found no relationship by class with incident cognitive decline or dementia. Diuretic use was suggestive of benefit in some analyses but results were not consistent across follow-up time, comparator group, and outcome. Limited data precluded meaningful analyses in those ≤65 years of age.CONCLUSION:Our findings, drawn from the current evidence base, support clinical freedom in the selection of antihypertensive regimens to achieve blood pressure goals.CLINICAL TRIALS REGISTRATION:The review was registered with the international prospective register of systematic reviews (PROSPERO), registration number CRD42016045454.

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 <0.001 for both. Higher pulse pressure variability was no longer associated with cognitive function after adjustment for age, except with residual SD ( 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 <0.01). Pulse pressure variability was not associated with dementia risk. Beyond hypertension, higher BPV is a major clinical predictor of cognitive impairment and dementia. Further studies are needed to assess whether controlling BP instability could be a promising interventional target in preserving cognition among older adults.

Context. Type 2 diabetes is a common disease in elderly patients. Complications may result in hospitalizations. Objective. Our objective was to identify risk factors for hospitalization in elderly patients with type 2 diabetes in real life. Methods. The S.AGES diabetes sub-cohort is a multicenter prospective study where 213 GPs have included 983 over 65 years of age not institutionalized type 2 diabetic patients. The occurrence of at least one hospitalization in the first year of follow-up was reported. A mixed logistic regression model was used for the analysis. Results. Of the 983 patients included in the baseline, 862 were analysed and 167 (19.4%) were hospitalized at least once. Risk factors associated with hospitalization were loss of autonomy measured by the ADL Clscore score ADL (OR=2.10; 95CI=1.32-3.50; p=0.001), history of cancer (OR=2.17; 95CI=1.54-3.48; p=0.001), heart failure (OR=2.31; 95CI=1.443.69; p=0.005) and polymedication (more than 5 different drugs per day: OR=1.59; 95CI=1.05-2.43; p=0.03. Conclusion. Comorbidities, loss of autonomy and polymedication were identified as the main risk factors for hospitalizations in elderly patients. Risk factors observed in our study were more ageing or specific disease related and encourage the overall management of the elderly whether diabetic or not.

AIMSThe 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.METHODS983 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.RESULTSAt 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.CONCLUSIONSElderly 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.

Objective: The aim of this study was to estimate the association between gender and control of diabetes and other cardiovascular risk factors in elderly patients with type 2 diabetes mellitus. Methods: The sujets ages cohort is an observational study whose main objective was to describe the real-life management of elderly patients with type 2 diabetes mellitus in France. Nine hundred eighty-three patients with diabetes (517 men and 466 women) were recruited by 213 general practitioners and were followed up prospectively every 6 months for 3 years. Diabetes, hypertension and dyslipidemia were considered controlled if the glycated hemoglobin (A1C) was <= 7%, blood pressure was <140/90 mm Hg and low-density lipoprotein (LDL) cholesterol was <= 100 mg/dL. A1C levels and blood pressure measurements were recorded every 6 months for all patients. LDL cholesterol levels were optionally sampled every year. Results: Women were older than men (77.3 +/- 5.72 vs 76.1 +/- 6.01 years), more likely to be alone, less likely to be smokers/ex-smokers and less likely to have cardiovascular disease at baseline. Mean A1C levels of female patients (6.98%+/- 1.03%) did not differ from those of male patients (6.91%+/- 0.96%). Mean blood pressure measurements duimg follow up were not different between male and female patients. In contrast, female patients had significantly higher LDL cholesterol levels than male counterparts (105.2 +/- 32.6 vs. 94.9 +/- 29.1 mg/dL), regardless of statin therapy. Conclusion: Our results suggest no difference in the management of cardiovascular risk factors between elderly female patients with type 2 diabetes mellitus and their male counterparts, except for LDL cholesterol, which is significantly higher in women. (C) 2017 Canadian Diabetes Association.

RésuméPour le gériatre, le vieillissement cérébral recouvre de nombreuses questions : le déclin cognitif est-il réel ou non ? Quelles sont les frontières entre vieillissement normal et pathologique ? Quels sont les rapports entre « oubli bénin » et démence ? Un des défis majeurs que le vieillissement du cerveau nous propose, c’est celui du traitement. De nombreux médicaments ont été utilisés, avec pour la plupart des résultats modestes.

Aim S.AGES is a multicenter prospective cohort study of non-institutionalized patients aged 65 and over with atrial fibrillation, type 2 diabetes or chronic pain. Its objective is to describe the medical management in primary care. This article presents the baseline characteristics of subjects in the diabetes subcohort and compares the results to those from cohorts of older diabetic patients. Methods From April 2009 to June 2011, 983 patients were included in the diabetes subcohort by 213 primary care providers. Demographic data, geriatric parameters and the history, characteristics and treatment of the diabetes were recorded at baseline. Results The mean age was 76.7 ± 5.9 years. Most patients were living independently, with no cognitive impairment and in relatively good health. The duration of diabetes was 11.3 ± 8.7 years with average HbA1c of 6.9 ± 1.0%. 20% of patients had macrovascular disease, 33% renal failure, 14.6% ocular complication and 7.1% neuropathy. The first-line antidiabetic treatment was metformin (61.2%) and 18% of patients had used insulin. Treatment intensified with the worsening of diabetic symptoms. When compared to those from French and North American cohorts, the results showed increased complications and use of insulin with age, disease duration and severity. Conclusion Due to the method of recruitment, S.AGES patients were generally healthy with well-controlled diabetes. However, the results were consistent with those from other cohorts. Three-year follow-up is expected to study the management of diabetic patients aged 65 and over in primary care.

The aim was to identify fall predictors in elderly suffering from chronic pain (CP) and to test their applicability among patients with other chronic conditions.

Concern about the renal safety of commonly used cardiovascular drugs with demonstrated clinical benefit appears to be an obstacle to their use in the elderly. The objective was to describe the relationship between cardiovascular drugs and chronic kidney disease ( CKD ) in elderly individuals in the real‐life setting. This is an ancillary study of the prospective non‐interventional S. AGE (aged individuals) cohort. General physicians were free to prescribe any drug their patients needed. The participants were non‐institutionalized patients aged 65 years and older treated by their primary physician for either chronic pain or atrial fibrillation or type 2 diabetes mellitus. The estimated glomerular filtration rate ( eGFR ) derived from the CKD ‐ EPI formula was determined at inclusion and every year during 2 years of follow‐up. This study comprised 2505 patients aged 77.8 ± 6.2 years. At inclusion, the factors associated with CKD ( eGFR < 60 ml/min/1.73 m 2 ) in multivariate analysis were age, female gender, hypertension, heart failure, history of atherothrombotic disease and renin angiotensin system blockers, loop diuretics and calcium channel inhibitors. Introduction of each of these three drug classes during the follow‐up period led to only a small decrease in the eGFR : −3.8 ± 12.7 ( p < 0.0006), −2.2 ± 12.0 ( p < 0.003) and −1.0 ± 13.4 ml/min./1.73 m 2 ( NS ), respectively. Only the introduction of loop diuretics was associated with CKD ( OR 1.91, 95% CI : 1.25–2.90; p = 0.002). Renal safety of cardiovascular drugs in the elderly appears acceptable and should not be a barrier to their use.

This study aimed to estimate the total healthcare costs associated with elderly chronic pain (CP) patients, define cost-related factors in this population, and examine cost evolution over two years.

Adaptation of drug dosage to kidney function is a common problem in general practice. The aim was to describe adaptation of cardiovascular drugs and metformin according to renal function and its association with mortality with regard to metformin in a cohort of elderly patients. This was an ancillary study to the S.AGES cohort made up of patients over 65 years of age managed by their general practitioner under real-life conditions and followed up prospectively for 3 years. The medications studied were digoxin, spironolactone and metformin. Adaptation of their daily dose according to renal function (eGFR according to CKD/EPI) was compared to that recommended in the summaries of product characteristics (SPCs) or international scientific societies (ISS). A total of 900 patients were included, including 588 on metformin. At baseline, dose adjustment according to renal function was 100% and 87.6% (95% CI: 82.6-92.6) for patients on digoxin and spironolactone respectively. For metformin, only 71.3% (95% CI: 67.6-74.9) or 78.1% (95% CI: 74.7-81.4) of patients had their dosage adapted at inclusion according to their renal function depending on whether the SPCs or ISS recommendations were considered. During the 3-year follow-up period, 42/588 patients died (none from lactic acidosis). At inclusion, a metformin dosage not adapted for renal function according to ISS was not associated with an increase in all-cause mortality (OR 1.7; 95% CI 0.6-5.0, p = 0.32). In conclusion, approximately one-quarter of elderly patients treated with metformin do not have their dosage adapted for renal function according to ISS although there is no increase in mortality after follow-up for 3 years.

OBJECTIVEThe aim of this study was to identify the relationship between general practitioner (GP) gender and prescribing practice of chronic pain drugs in older adults.DESIGNCross-sectional observational study.SETTINGGPs in private practice throughout France.SUBJECTSTwo hundred and sixty GPs (80.8% male and 19.2% female) enrolled 1,379 (28.4% male and 71.6% female) noninstitutionalized patients over 65 years of age, suffering from chronic pain.METHODSA comparison of prescribing habits between male and female GPs was performed on baseline data with univariate analyses followed by multivariate analyses after taking several confounding factors into account.RESULTSNo significant differences were found when comparing male and female GPs' prescriptions of World Health Organization step 1, step 2, and step 3 analgesics. Male GPs were more likely than female GPs to prescribe antineuropathic pain drugs (11.3% of patients with male GPs versus 4.8% of patients with female GPs, P = 0.004) and less likely to prescribe symptomatic slow-acting drugs for osteoarthritis (SySADOA) (10.2% of male GPs' patients versus 18.8% of female GPs' patients, P = 0.0003). After adjusting for several confounding factors, male GPs were still more likely to prescribe antineuropathic pain drugs (OR 2.43, 95% CI 1.15-5.14, P = 0.02) and less likely to prescribe symptomatic slow-acting drugs (OR 0.64, 95% CI 0.42-0.97, P = 0.03).CONCLUSIONMale and female GPs prescribe analgesics in a similar manner. However, male GPs prescribe more antineuropathic pain drugs, but fewer SySADOA.

Objective Describe the consequences of dextropropoxyphene (DXP) market withdrawal on analgesic prescriptions and on the quality of therapeutic management of chronic pain. Patients and methods From a cohort of non-institutionalised elderly patients with chronic pain recruited by general practitioners, we selected patients who were treated with DXP daily for at least 6 months just prior to DXP market withdrawal and who had an evaluation of pain and its impact on daily activities before and after DXP withdrawal. Results One hundred three patients took DXP daily for chronic pain. Immediately after DXP market withdrawal, 42 (40.8 %), 55 (53.4 %) and 3 (2.9 %) patients were treated with step 1, 2 and 3 analgesics, respectively, and 3 patients (2.9 %) were no longer receiving any analgesic medication. Among the 55 patients who continued on step 2 analgesics, 37 were treated with tramadol, 14 with codeine and 9 with opium. Pain intensity and the impact of pain on daily activities remained stable. Conclusion DXP market withdrawal had no consequences on the intensity or impact of chronic pain in elderly patients.

Journal of Hypertension 2013, 31:1868–1875 Imperial College London UK, Department of Cardiovascular Diseases, The Studies Coordinating Centre, Division of Hypertension and Cardiovascular Rehabilitation, University of Leuven, Leuven, Belgium, Centre for Epidemiological Studies and Clinical Trials, The Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China, Hôpital Broca, Centre de Gerontologie, 54-56 rue Pascal, 75013 Paris France and London School of Hygiene and Tropical Medicine, London, UK

The primary objective of the S.AGES cohort is to describe the real-life therapeutic care of elderly patients. Patients and methods. This is a prospective observational cohort study of 3 700 non-institutionalized patients over the age of 65 years with either type 2 diabetes mellitus (T2DM), chronic pain or atrial fibrillation (AF) recruited by French general practitioners (GPs). Follow-up is planned for 3 years. Baseline characteristics. In the chronic pain sub-cohort, 33% of patients are treated with only grade 1 analgesics, 29% with grade 2 analgesics and 3% with grade 3 analgesics, and 22% have no pain treatment. In the T2DM sub-cohort, 61% of patients have well-controlled diabetes (Hb1c<7%) and 18% are treated with insulin. In the AF sub-cohort, 65% of patients have a CHADS2 score greater than 2, 77% are treated with oral anticoagulants, 17% with platelet inhibitors, 40% with antiarrhythmic drugs and 56% with rate slowing medications. Conclusion. The S.AGES cohort presents a unique opportunity to clarify the real-life therapeutic management of ambulatory elderly subjects and will help to identify the factors associated with the occurrence of major clinical events.

Objectives:High blood pressure (BP) has been associated with increased risk of dementia. Concerns have been raised about lowering BP too far in the very elderly and thereby increasing risk. There is some evidence to suggest a potential J'-shaped relationship between DBP and risk of cognitive impairment. This was investigated using data from the HYpertension in the Very Elderly Trial (HYVET).Methods:HYVET was a double-blind, placebo-controlled trial of antihypertensives in patients aged at least 80 years with an untreated SBP of 160-199mmHg. Active medication was indapamide sustained release 1.5mg+/- perindopril 2-4mg to reach goal pressure of less than 150/80mmHg. Incident dementia was a secondary endpoint and was not significantly different between the two treatment groups. The relationship between pressure and incident dementia was assessed using Cox proportional hazards regression with BP entered as either a discrete (quartile analysis) or continuous predictor variable. Achieved BP was calculated as the mean of all pressures from the 9 month visit onwards.Results:During a mean follow-up of 2.2 years 263 incident cases of dementia were diagnosed. After adjustment for various covariates, baseline DBP was inversely related to incident dementia (P=0.0064). Achieved DBP did not predict later dementia in the placebo group (P=0.43), but showed a U-shaped relationship in the active treatment group (P=0.0195). The relationship between incident dementia and DBP did however not differ significantly between the placebo and active treatment groups (P=0.38). SBP was not associated with incident dementia, at baseline (P=0.62) or during follow-up (placebo group P=0.13, active group P=0.36). Wider achieved pulse pressure (PP) was associated with increased risk of dementia in both treatment groups (placebo P=0.032, active P=0.0046). The same tendency was observed for baseline PP (P=0.095).Conclusion:Wider PP may possibly indicate an increased risk for dementia. Active treatment may act to change the shape of the relationship between DBP and dementia. Future studies need to focus on exploring the ideal goal pressure for this age group.

Atrial fibrillation (AF) is a common and serious condition in the elderly. AF affects between 600,000 and one million patients in France, two-thirds of whom are aged above 75 years. AF is a predictive factor for mortality in the elderly and a major risk factor for stroke. Co-morbidities are frequent and worsen the prognosis. The management of AF in the elderly should involve a comprehensive geriatric assessment (CGA), which analyses both medical and psychosocial elements, enabling evaluation of the patient's functional status and social situation and the identification of co-morbidities. The CGA enables the detection of "frailty" using screening tools assessing cognitive function, risk of falls, nutritional status, mood disorders, autonomy and social environment. The objectives of AF treatment in the elderly are to prevent AF complications, particularly stroke, and improve quality of life. Specific precautions for treatment must be taken because of the co-morbidities and age-related changes in pharmacokinetics or pharmacodynamics. Preventing AF complications relies mainly on anticoagulant therapy. Anticoagulants are recommended in patients with AF aged 75 years or above after assessing the bleeding risk using the HEMORR2HAGES or HAS-BLED scores. Novel oral anticoagulants (NOACs) are promising treatments, especially due to a lower risk of intracerebral haemorrhage. However, their prescriptions should take into account renal function (creatinine clearance assessed with Cockcroft formula) and cognitive function (for adherence to treatment). Studies including frail patients in "real life" are necessary to evaluate tolerance of NOACs. Management of AF also involves the treatment of underlying cardiomyopathy and heart rate control rather than a rhythm-control strategy as first-line therapy for elderly patients, especially if they are paucisymptomatic. Antiarrhythmic drugs should be used carefully in elderly patients because of the frequency of metabolic abnormalities and higher risk of drug interactions and bradycardia.