Comprehensive Geriatric Assessment and 2-Year Mortality in Elderly Patients Hospitalized for Heart Failure

Comprehensive Geriatric Assessment to Optimize the Management of Older Patients With Transthyretin Cardiac Amyloidosis

Transthyretin cardiac amyloidosis (ATTR-CA) predominantly affects older adults with multiple chronic conditions, leading to significant physical, cognitive, and emotional challenges. New disease-modifying drugs are effective in early stages, prompting a shift toward comprehensive assessments, including functional capacity and quality of life. However, these assessments may not fully capture the complexity of older ATTR-CA patients, especially regarding frailty and mood disorders, which can influence symptom reporting. Thus, integrating comprehensive geriatric assessment tools into routine clinical practice may be crucial to detect early signs of frailty or functional impairment that could impact outcomes and mitigate futility and ageism in the decision-making process. This review highlights the importance of evaluating multimorbidity, disability, and frailty in older patients with ATTR-CA to optimize management strategies.

Effects of SGLT2-Inhibitors on Comprehensive Geriatric Assessment, Biomarkers of Oxidative Stress, and Platelet Activation in Elderly Diabetic Patients with Heart Failure with Preserved Ejection Fraction

BACKGROUND

Heart failure (HF) with preserved ejection fraction (HFpEF) represents a major comorbidity in the elderly and is associated with cognitive impairment (CoI) and type 2 diabetes mellitus (T2DM). In this context, there is an increase in oxidative stress and platelet activation biomarkers. The aim of this study was to evaluate the effects of 6 months' treatment with SGLT2i on functional, mood-related, and cognitive aspects, assessed by performing a comprehensive geriatric assessment (CGA), and on oxidative stress and platelet activation biomarkers, in a cohort of HFpEF elderly patients with T2DM. We recruited 150 elderly outpatients (mean age 75.8 ± 7.4 years).

RESULTS

At six-month follow-up, there was a significant improvement in MMSE (p < 0.0001), MoCA (p < 0.0001), GDS score (p < 0.0001), and SPPB (p < 0.0001). Moreover, we observed a significant reduction in Nox-2 (p < 0.0001), 8-Isoprostane (p < 0.0001), Sp-Selectin (p < 0.0001), and Gp-VI (p < 0.0001). Considering ΔMMSE as the dependent variable, ΔE/e', ΔNox-2, ΔHOMA, Δ8-Isoprostane, and ΔUricemia were associated for 59.6% with ΔMMSE. When ΔMoCA was considered as the dependent variable, ΔHOMA, ΔE/e', Δ8-Isoprostane, ΔNox-2 and ΔUricemia were associated for 59.2%. Considering ΔGDS as the dependent variable, ΔHOMA, ΔNox-2, Δ8-Isoprostane, and ΔUricemia were associated with 41.6% of ΔGDS variation. Finally, ΔHOMA was the main predictor of ΔSPPB, which was associated with 21.3% with ΔSPPB, Δ8-Isoprostane, ΔNox-2, ΔE/e', and ΔUricemia added another 24.1%.

CONCLUSION

The use of SGLT2i in elderly patients with T2DM and HFpEF significantly contributes to improving CGA scales and biomarkers of OS and PA.

Prognostic Features of Sarcopenia in Older Hospitalized Patients: A 6-Month Follow-Up Study

Background: Sarcopenia is associated with adverse health outcomes. Understanding the association between sarcopenia, multidimensional frailty, and prognosis is essential for improving patient care. The aim of this study was to assess the prevalence and prognostic signature of sarcopenia in an acute hospital setting co-led by internists and geriatricians. Methods: Sarcopenia was assessed by applying the European Working Group on Sarcopenia in Older People (EWGSOP2) algorithm, including the SARC-F score, handgrip strength, bioelectrical impedance analysis (BIA), and Timed Up and Go (TUG) test, to 97 older multimorbid inpatients (76.5 ± 6.8 years, 55% women). The patients underwent a Comprehensive Geriatric Assessment (CGA) including an evaluation of Geriatric Syndromes (GSs) and Resources (GR) and prognosis calculation using the CGA-based Multidimensional Prognostic Index (MPI), European Quality of life-5 Dimensions (EQ-5D-5L) scale, Rosenberg Self-Esteem Scale (RSES), and Geriatric Depression Scale (GDS). Information on survival and rehospitalizations was collected 1, 3, and 6 months after discharge. Results: Sarcopenia was present in 63% (95% CI: 54-72%) of patients and categorized as probable (31%), confirmed (13%), and severe sarcopenia (18%). Sarcopenic patients showed significantly higher median MPI-values (p < 0.001), more GSs (p = 0.033), fewer GR (p = 0.003), lower EQ-5D-5L scores (p < 0.001), and lower RSES scores (p = 0.025) than non-sarcopenic patients. Six months after discharge, being sarcopenic at baseline was predictive of falls (p = 0.027) and quality of life (p = 0.043), independent of age, gender, and MPI. Conclusions: Sarcopenia is highly prevalent in older hospitalized multimorbid patients and is associated with poorer prognosis, mood, and quality of life up to 6 months after discharge, independent of age, sex, and MPI as surrogate markers of biological age.

Educational status affects prognosis of patients with heart failure with reduced ejection fraction: A post-hoc analysis from the WARCEF trial

AIMS

The influence of social determinants of health (SDOH) on the prognosis of Heart Failure and reduced Ejection Fraction (HFrEF) is increasingly reported. We aim to evaluate the contribution of educational status on outcomes in patients with HFrEF.

METHODS

We used data from the WARCEF trial, which randomized HFrEF patients with sinus rhythm to receive Warfarin or Aspirin; educational status of patients enrolled was collected at baseline. We defined three levels of education: low, medium and high level, according to the highest qualification achieved or highest school grade attended. We analysed the impact of the educational status on the risk of the primary composite outcome of all-cause death, ischemic stroke (IS) and intracerebral haemorrhage (ICH); components of the primary outcome were also analysed as secondary outcomes.

RESULTS

2295 patients were included in this analysis; of these, 992 (43.2%) had a low educational level, 947 (41.3%) had a medium education level and the remaining 356 (15.5%) showed a high educational level. Compared to patients with high educational level, those with low educational status showed a high risk of the primary composite outcome (adjusted hazard ratio [aHR]: 1.31, 95% confidence intervals [CI] 1.02-1.69); a non-statistically significant association was observed in those with medium educational level (aHR: 1.20, 95%CI: .93-1.55). Similar results were observed for all-cause death, while no statistically significant differences were observed for IS or ICH.

CONCLUSION

Compared to patients with high educational levels, those with low educational status had worse prognosis. SDOH should be considered in patients with HFrEF.

CLINICAL TRIAL REGISTRATION

NCT00041938.

Usefulness of Clinical Frailty Scale for Comprehensive Geriatric Assessment of Older Heart Failure Patients

Background: Comprehensive geriatric assessment (CGA) is a multidisciplinary diagnostic process to identify the physical, psychological, and social functions of patients with frailty. The Clinical Frailty Scale (CFS) might aid in effectively identifying older patients with heart failure (HF) and frailty who would then reap maximum benefits from the CGA. Methods and Results: A single-centre prospective cohort study that enrolled consecutive hospitalised patients (age ≥75 years) with HF was conducted. The Barthel index (BI), Mini Mental State Examination (MMSE), the Charlson comorbidity index (CCI), and the COntrolling NUTritional (CONUT) for CGA was used. Among 190 enrolled patients (mean age, 85.4 years; 47.9% male), all-cause mortality (primary endpoint) occurred in 45 patients and HF-related rehospitalization (secondary endpoint) in 59 patients within 1 year. The cumulative incidence of all-cause mortality was significantly higher in the high CFS group (low 6.3%, high 30.5%, P<0.001). However, the cumulative incidence of HF-related rehospitalization was not significantly different (low 26.3%, high 32.0%, P=0.304). The multivariable analysis revealed that the CFS group was independently associated with the risk of all-cause mortality. CFS showed a strong correlation with the BI and moderate correlation with the MMSE. Conclusions: The CFS was associated with all-cause mortality within 1 year and was correlated with frailty domains of CGA.

Impairments identified by comprehensive geriatric assessment in potential candidates for left ventricular assist device and heart transplantation

Background

The aim of this study was to assess the prevalence of frailty and other impairments in potential left ventricular assist device (LVAD) and heart transplantation (HTx) candidates by performing a preoperative comprehensive geriatric assessment (CGA) and reviewing the treatment recommendations resulting from the CGA.

Methods and results

This cross-sectional study included 73 patients aged ≥40 years who received a CGA as part of the patient selection procedure for LVAD and HTx. In every patient, a conclusion comprising frailty and other impairments was formulated based on the medical, mental, functional, and social domains and recommendations were made. The mean age was 58 years (range 40-71) and 70 % were male. In 97 % of patients, at least one impairment was identified by the CGA. The most common impairments were polypharmacy, high morbidity burden, reduced renal function, osteopenia, depression, poor quality of life, reduced functionality, (risk of) malnutrition, reduced grip strength and high caregiver burden. A small proportion of the potential LVAD and HTx candidates were frail (7 % according to Fried's frailty criteria, 6 % according to the Edmonton Frail Scale) and 39 % were pre-frail. The domains for which most impairments were found and the domains for which most treatment recommendations were given matched well, with the functional domain as the frontrunner.

Conclusion

This study showed that most of the potential candidates for LVAD or HTx have impairments on at least one domain of the CGA. Impairments and associated risks can contribute to the decision making process for candidacy for LVAD and HTx.

Short term effect of sacubitril/valsartan on comprehensive geriatric assessment in chronic heart failure: a real life analysis

Sacubitril/Valsartan (Sac-Val) has improved clinical prognosis in patients affected by heart failure (HF) with reduced ejection fraction (HFrEF). Comorbidities have a crucial impact on clinical presentation and prognosis in HF patients. Cognitive impairment (CoI) and Depression are a very common comorbidity in patients with HF and is widely recognized as a specific determinant of chronic disability, and HF patients with poor physical functional performance in Short physical performance battery (SPPB) showed a worse prognosis. The aim of the present study was to evaluate the potential effects of Sac-Val on functional, humoral, and cognitive aspects, evaluated by performing comprehensive geriatric assessment (CGA), in a cohort of elderly HFrEF. We studied 61 patients (51 men and 10 women, mean age 76.4 ± 5.1 years) suffering from HFrEF. After 6 months follow-up, we observed a significant improvement in humoral and functional parameters of CGA, renal function, NTpro-BNP levels and echocardiographic parameters. In the whole population, multivariate analysis shows that changes of Cardiac Index, NT-proBNP and Respiratory rate contributed for 26.0%, 9.7% and 4.8% to GDS variability, respectively, and the whole model accounted for a 41.1% of GDS variation; moreover changes of Global longitudinal strain, estimated glomerular filtration rate, Cardiac Index and BMI contributed for 23.9%, 11.7%, 5.4% and 4.0% to SPPB variability, respectively, and the whole model accounted for a 45% of SPPB variation. This represents the first real-world study carried out in an elderly population suffering from chronic HFrEF with numerous comorbidities, in which treatment with Sac-Val for 6 months induced important improvements in clinical, humoral, hemodynamic, and functional outcomes, without adverse effects on cognitive performance.

Prevalence and Prognosis Impact of Frailty Among Older Adults in Cardiac Intensive Care Units

Background

Whether frailty, defined as a biological syndrome that reflects a state of decreased physiological reserve and vulnerability to stressors, may impact the outcomes of elderly patients admitted to a cardiac intensive care unit (CICU) remains unclear. We aimed to determine the prevalence of frailty and its impact on mortality in patients aged ≥ 80 years admitted to a CICU.

Methods

This prospective single-centre observational study was conducted among patients aged ≥ 80 years admitted to a CICU in a tertiary centre. Frailty was assessed using the Edmonton Frail Scale (EFS), which provides a score ranging from 0 (not frail) to 17 (very frail). The population was divided into 3 classes: EFS-score of 0-3, EFS-score of 4-6, and EFS-score > 7.

Results

A total of 199 patients were included, and median follow-up duration was 365 days. The mean age was 84.8 years, and 50 patients (25.1%) died during the follow-up period. In all, 45 (22.6%), 60 (30.2%), and 94 patients (47.2%) had an EFS-score of 0-3, 4-6, and ≥ 7, respectively. The all-cause mortality rate was 4.4%, 27.1%, and 37.2% in the 0-3, 4-6, and ≥ 7 EFS-score groups, respectively (P < 0.001). After multivariate analysis, frailty status remained associated with all-cause mortality: hazard ratio was 2.60 (95% confidence interval 0.54-12.45) within the 4-6 EFS-score group, and 5.46 (95% confidence interval 1.23-24.08) within the ≥ 7 EFS-score group.

Conclusions

Frailty is highly prevalent in older adults admitted to the population hospitalized in a CICU and represents a strong prognostic factor for 1-year all-cause mortality.

Prioritizing movement to address the frailty phenotype in heart failure

Frailty is a highly prevalent multisystem syndrome in older adults with heart failure (HF) and is associated with poor clinical prognosis and increased complexity of care. While frailty is neither disease nor age specific, it is a clinical manifestation of aging-related processes that reflects a reduced physiological ability to tolerate and recover from stress associated with aging, disease, or therapy. Within this context, physical frailty, which is distinctly oriented to physical functional domains (e.g., muscle weakness, slowness, and low activity), has been recognized as a critical vital sign in older persons with HF. Identification and routine assessment of physical frailty, using objective physical performance measures, may guide the course of patient-centered treatment plans that maximize the likelihood of improving clinical outcomes in older HF patients. Exercise-based rehabilitation is a primary therapy to improve cardiovascular health in patients with HF; however, the limited evidence supporting the effectiveness of exercise tailored to older and frail HF patients underscores the current gaps in management of their care. Interdisciplinary exercise interventions designed with consideration of physical frailty as a therapeutic target may be an important strategy to counteract functional deficits characteristic of frailty and HF, and to improve patient-centered outcomes in this population. The purpose of this current review is to provide a better understanding of physical frailty and its relation to management of care in older patients with HF. Implications of movement-based interventions, including exercise and physical rehabilitation, to prevent or reverse physical frailty and improve clinical outcomes will further be discussed.

Impacts of Heart Failure and Physical Performance on Long-Term Mortality in Old Patients With Chronic Kidney Disease

Background: In patients with chronic kidney disease (CKD), physical functional limitations and heart failure (HF) are common, and each is associated with adverse outcomes. However, their joint effects on mortality are not clear.

Design and Methods: Using administration data from the geriatric department in a tertiary hospital, retrospective longitudinal analyses of patients aged ≥65 years with CKD were consecutively enrolled from February 2010 to November 2015. Baseline CKD stages, HF with reduced and preserved ejection fraction (HFrEF and HFpEF), Rockwood frailty index, handgrip strength (HGS), 6-m walking speed, and timed up-and-go test were used to predict the prevalence of frailty, physical disability, and all-cause mortality.

Results: Among 331 old patients with CKD, their mean age was 81.3 ± 6.6 years. CKD stages showed the following distributions: stage 3, 74.9%; stage 4, 15.7%; stage 5, 9.4%. The prevalence of HF was 23.3%, and Rockwood frailty was 74.3%. Rockwood frailty and HF were both significantly associated with CKD stages. After a mean follow-up period of 3.1 ± 2.1 years, 44 patients died, and a crude analysis showed that stage 4, stage 5 CKD, low HGS, and Rockwood frailty index were associated with mortality. Regarding the survival of these patients, the adjusted mortality hazard ratio for CKD stage 5 was 3.84 against stage 3A [95% confidence interval (CI) 1.51–9.75], 1.04 (95% CI 1.01–1.07) for higher Rockwood frailty score, 4.78 (95% CI 1.26–18.11) for HFrEF, and 3.47 (95% CI 1.15–10.42) for low HGS. Survival analysis using Kaplan–Meier survival plots showed that patients with both HF and poor HGS had the poorest survival.

Conclusions: Our study shows that both low physical performance and HF were common in old CKD patients and were associated with CKD stages. HF, frailty, and HGS all independently predicted the mortality of these CKD patients. The mortality is especially high amongst individuals with both HF and decreased HGS.

Activities of daily living associated with postoperative intensive care unit survival in elderly patients following elective major abdominal surgery: An observational cohort study

Elderly patients who undergo major abdominal surgery are being in increasing numbers. Intensive care unit (ICU) survival is critical for surgical decision-making process. Activities of daily living (ADL) are associated with clinical outcomes in the elderly. We aimed to investigate the relationship between ADL and postoperative ICU survival in elderly patients following elective major abdominal surgery.We conducted a retrospective cohort study involving patients aged ≥65 years admitted to the surgical intensive care unit (SICU) following elective major abdominal surgery. Data from all patients were extracted from the electronic medical records. The Barthel Index (BI) was used to assess the level of dependency in ADL at the time of hospital admission.ICU survivors group had higher Barthel Index (BI) scores than non-survivors group (P < .001). With the increase of BI score, postoperative ICU survival rate gradually increased. The ICU survivals in patients with BI 0-20, BI 21-40, BI 41-60, BI 61-80 and BI 81-100 were 55.7%, 67.6%, 72.4%, 83.3% and 84.2%, respectively. In logistic regression, The Barthel Index (BI) was significantly correlated with the postoperative ICU survival in elderly patients following elective major abdominal surgery (OR = 1.33, 95% CI: 1.20-1.47, P = .02). The area under the receiver operating characteristic (ROC) curve of Barthel Index in predicting postoperative ICU survival was 0.704 (95% CI, 0.638-0.771). Kaplan-Meier survival curve in BI≥30 patients and BI < 30 patients showed significantly different.Activity of daily living upon admission was associated with postoperative intensive care unit survival in elderly patients following elective major abdominal surgery. The Barthel Index(BI) ≥30 was associated with increased postoperative ICU survival. For the elderly with better functional status, they could be given more surgery opportunities. For those elderly patients BI < 30, these results provide useful information for clinicians, patients and their families to make palliative care decisions.

Multidomain Frailty in Heart Failure: Current Status and Future Perspectives

PURPOSE OF REVIEW

With a worldwide aging population, frailty and heart failure (HF) have become issues that need to be addressed urgently in cardiovascular clinical practice. In this review, we outline the clinical implications of frailty in HF patients and the potential therapeutic strategies to improve the clinical outcomes of frail patients with HF.

RECENT FINDINGS

Frailty has physical, psychological, and social domains, each of which is a prognostic determinant for patients with HF, and each domain overlaps with the other, although there are no standardized criteria for diagnosing frailty. Frailty can be targeted for treatment with various interventions, and recent studies have suggested that multidisciplinary intervention could be a promising option for frail patients with HF. However, currently, there is limited data, and further research is needed before its clinical implementation. Frailty and HF share a common background and are strongly associated with each other. More comprehensive assessment and therapeutic interventions for frailty need to be developed to further improve the prognosis and quality of life of frail patients with HF.

Identification of comprehensive geriatric assessment-based risk factors for insomnia in elderly Chinese hospitalized patients

OBJECTIVE

Insomnia is a common problem in older persons and is associated with poor prognosis from a functional or clinical perspective. The purpose of this study was to investigate the prevalence of insomnia and identify comprehensive geriatric assessment (CGA) based clinical factors associated with insomnia in elderly hospitalized patients.

METHODS

Standardized face-to-face interviews were conducted and CGA data were collected from 356 Chinese hospitalized patients aged 60 years or older. Insomnia was defined as self-reported sleep poor quality according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-Ⅴ). Multivariate logistic regression analysis was applied to assess the association between patient clinical factors together with domains within the CGA and insomnia.

RESULTS

Among the 365 patients, insomnia was found in 48.31% of the participants. Difficulty in initiating sleep (DIS), early morning awakening (EMA), difficulty in maintaining sleep (DMS), and snoring were found in 33.99%, 9.55%, 13.48%, and 1.69% of patients, respectively. Significant associations were found between insomnia and several covariates: female gender (P = 0.034), depression (P = 0.001), activities of daily living (ADL) (P = 0.034), instrumental activities of daily living (IADL; P = 0.009), falling (P = 0.003), chronic pain (P = 0.001), and poor nutritional status (P = 0.038). According to the results of the adjustment multivariate logistic regression analysis, female sex (odds ratio [OR] = 2.057, confidence interval [CI] = 1.179-3.588, P = 0.011), depression (OR = 1.889, CI = 1.080-3.304, P = 0.026), and chronic pain (OR = 1.779, CI = 1.103-2.868, P = 0.018) were significant independently predictors associated with insomnia.

CONCLUSIONS

Our study revealed that female sex, depression, and chronic pain were independently predictors of insomnia in hospitalized patients. Early identification of elderly patients with these risk factors using the CGA may improve the quality of life and treatment outcomes.

Physical frailty and long-term mortality in older people with chronic heart failure with preserved and reduced ejection fraction: a retrospective longitudinal study

BACKGROUND

Frailty, a syndrome characterized by a decline in function reserve, is common in older patients with heart failure (HF) and is associated with prognosis. This study aimed to evaluate the impact of frailty on outcomes in older patients with preserved and reduced cardiac function.

METHODS

In total, 811 adults aged ≥65 years were consecutively enrolled from 2009 to 2018. HF was diagnosed according to the ICD9 code and a 2D echocardiogram was categorized by reduced ejection fraction (HFrEF) and preserved ejection fraction (HFpEF). The index date was registered at the time of HF. All patients received a comprehensive geriatric assessment, and clinical outcomes were examined with adjustment of the other prognostic variables.

RESULTS

Mean age was 80.5 ± 7.1 years. The prevalence of HF, HFpEF, HFrEF, Fried, and Rockwood frailty indicators was 28.5, 10.4, 9.7, 52.5, and 74.9%, respectively. At baseline, scores in the Timed Up and Go test was closely associated with the severity of HF, either with HFpEF or HFrEF. After a mean follow-up of 3.2 ± 2.0 years, we found that HF patients with low handgrip strength (HGS) had the poorest survival, followed by non-HF patients with decreased HGS, and HF with fair HGS in comparison with non-HF with fair HGS (p = 0.008) if participants were arbitrarily divided into two HGS groups. In all patients, a high Rockwood frailty index was independently associated with increased mortality (adjusted hazard ratio [aHR] = 1.05; 95% confidence interval [CI]: 1.0004 to 1.10). In addition, the adjusted mortality HR was 3.42 with decreased HGS (95% CI: 1.03 to 11.40), 7.65 with use of mineralocorticoid receptor antagonist (95% CI: 2.22 to 26.32), and 1.26 with associated multi-comorbidities assessed by Charlson comorbidity index (95% CI: 1.05 to 1.51).

CONCLUSIONS

Our study results indicate that frailty and decreased physical functions were associated with HF. Besides, frailty and HGS predicted prognosis in the patients, and there was a combined effect of HF and low HGS on survival.

[Cross-speciality geriatrics: A health-care challenge for the 21st century]

Increasing numbers of older persons are being treated by specialties other than Geriatric Medicine. Specialists turn to Geriatric Teams when they need to accurately stratify their patients' risk and prognosis, predict the potential impact of their, often, invasive interventions, optimise their clinical status, and contribute to discharge planning. Oncology and Haematology, Cardiology, General Surgery, and other surgical departments are examples where such collaborative working is already established, to a varying extent. The use of the term "Cross-speciality Geriatrics" is suggested when geriatric care is provided in clinical areas traditionally outside the reach of Geriatric Teams. The core principles of Geriatric Medicine (comprehensive geriatric assessment, patient-centred multidisciplinary targeted interventions, and input at point-of-care) are adapted to the specifics of each specialty and applied to frail older patients in order to deliver a holistic assessment/treatment, better patient/carer experience, and improved clinical outcomes. Using Comprehensive Geriatric Assessment methodology and Frailty scoring in such patients provides invaluable prognostic information, helps in decision making, and enables personalised treatment strategies. There is evidence that such an approach improves the efficiency of health care systems and patient outcomes. This article includes a review of these concepts, describes existing models of care, presents the most commonly used clinical tools, and offers examples of excellence in this new era of geriatric care. In an ever ageing population it is likely that teams will be asked to provide Cross-specialty Geriatrics across different Health Care systems. The fundamentals for its implementation are in place, but further evidence is required to guide future development and consolidation, making it one of the most important challenges for Geriatrics in the coming years.

Older Adults in the Cardiac Intensive Care Unit: Factoring Geriatric Syndromes in the Management, Prognosis, and Process of Care: A Scientific Statement From the American Heart Association

Longevity is increasing, and more adults are living to the stage of life when age-related biological factors determine a higher likelihood of cardiovascular disease in a distinctive context of concurrent geriatric conditions. Older adults with cardiovascular disease are frequently admitted to cardiac intensive care units (CICUs), where care is commensurate with high age-related cardiovascular disease risks but where the associated geriatric conditions (including multimorbidity, polypharmacy, cognitive decline and delirium, and frailty) may be inadvertently exacerbated and destabilized. The CICU environment of procedures, new medications, sensory overload, sleep deprivation, prolonged bed rest, malnourishment, and sleep is usually inherently disruptive to older patients regardless of the excellence of cardiovascular disease care. Given these fundamental and broad challenges of patient aging, CICU management priorities and associated decision-making are particularly complex and in need of enhancements. In this American Heart Association statement, we examine age-related risks and describe some of the distinctive dynamics pertinent to older adults and emerging opportunities to enhance CICU care. Relevant assessment tools are discussed, as well as the need for additional clinical research to best advance CICU care for the already dominating and still expanding population of older adults.

Recommendations of the Geriatric Cardiology Section of the Spanish Society of Cardiology for the Assessment of Frailty in Elderly Patients With Heart Disease

Frailty is an age-associated clinical syndrome characterized by a decrease in physiological reserve in situations of stress, constituting a state of vulnerability that involves a higher risk of adverse events. Its prevalence in Spain is high, especially in elderly individuals with comorbidity and chronic diseases. In cardiovascular disease, frailty is associated worse clinical outcomes and higher morbidity and mortality in all scenarios, in both acute and chronic settings, and could consequently influence diagnosis and treatment. However, frailty is often not addressed or included when planning the management of elderly patients with heart disease. In this article, we review the available scientific evidence and highlight the most appropriate scales for the measurement and assessment of frailty, some of which are more useful and have better predictive capacity than others, depending on the clinical context. We also underline the importance of properly identifying and assessing frailty in order to include it in the treatment and care plan that best suits each patient.

Predicting in-hospital mortality in older general surgical patients

Introduction A significant number of emergency general surgical admissions occur in older patients. Clinical decision making in this group is challenging and current risk prediction tools extrapolate data from cohorts of younger patients. This is the first UK study to examine risk factors predicting in-hospital mortality in older acute surgical patients undergoing comprehensive geriatric assessment. Methods This was a prospective study of consecutive patients aged ≥75 years admitted non-electively to general surgery wards between September 2014 and February 2017 who were reviewed by an elderly medicine in-reach service. Results A total of 577 patients were included with a mean age of 82.9 years. There was a female predominance (56%). The majority were living at home alone or with carers (93%) and most were independent in basic activities of daily living (79%). Over two-thirds (69%) were mobile with no walking aids or use of a walking stick and overt here-quarters (79%) had no cognitive impairment. Seventy-seven per cent of patients were managed non-operatively. The in-hospital mortality rate was 6.9%. Female sex (p=0.031), dependence in activities of daily living (p<0.001), cognitive impairment (p<0.001) and incontinence (p<0.001) were predictors of in-hospital mortality. ASA (American Society of Anesthesiologists) grade ≥3 was also associated with increased in-hospital mortality (odds ratio: 5.3, 95% confidence interval: 2.6-10.7). Conclusions Older general surgical patients present a high level of complexity. This study highlights the predictive role of mobility, functional and cognitive impairment when assessing this population. Accurate risk stratification requires global assessment by teams experienced in care of the older patient rather than the traditional focus on co-morbidities.

Editor's Choice - Frailty and the management of patients with acute cardiovascular disease: A position paper from the Acute Cardiovascular Care Association

Frailty is increasingly seen among patients with acute cardiovascular disease. A combination of an ageing population, improved disease survival, treatable long-term conditions as well as a greater recognition of the syndrome has accelerated the prevalence of frailty in the modern world. Yet, this has not been matched by an expansion of research. National and international bodies have identified acute cardiovascular disease in the frail as a priority area for care and an entity that requires careful clinical decisions, but there remains a paucity of guidance on treatment efficacy and safety, and how to manage this complex group. This position paper from the Acute Cardiovascular Care Association presents the latest evidence about frailty and the management of frail patients with acute cardiovascular disease, and suggests avenues for future research.

In-hospital mortality risk score for very old patients hospitalized with decompensated chronic heart failure

OBJECTIVE

To derive a risk score to predict in-hospital mortality for very old patients with decompensated chronic heart failure (DCHF).

METHODOLOGY

Retrospective cohort study that included patients ≥ 80 years admitted to a Geriatric Acute Care Unit with DCHF between January 2012 and December 2014. We analyzed 70 candidate risk factors and in-hospital mortality. We derived a risk model using multivariate logistic regression model and constructed a scale for scoring risk. We used bootstrapping techniques for the internal validation.

RESULTS

We included 629 patients with mean age of 90 (SD5) years, 470 (73.1%) being women. Eighty-six (13.7%) patients died during the hospitalization. Factors included in the final risk model were NYHA class III-IV, severe functional dependence (Katz activities of daily living index < 2), infection as cause of exacerbation of heart failure, number of medications ≥ 8, albumin < 3 mg/dL, glomerular filtration rate < 60 mL/min, level of potassium in blood > 5.5 mEq/L and red blood cell distribution width (RDW) > 17%. In-hospital mortality in risk groups was 3.0, 4.6, 9.5, 15.1 and 36.3%, respectively. The area under ROC curve risk for score after bootstrapping was 0.77 (95%: CI 0.70-0.83).

CONCLUSION

This risk score could be useful for stratifying risk for in-hospital mortality among very old patients admitted to hospital for DCHF.

Basal functional status predicts one-year mortality after a heart failure hospitalization in elderly patients - The RICA prospective study

BACKGROUND

Dependence for basic activities of the daily living (ADL) relates to adverse outcomes in elderly acute heart failure (AHF) patients.

METHODS

We evaluated patients ≥75years admitted because of AHF, divided according to preadmission Barthel Index (BI) category: severe (BI 0-60), moderate (BI 61-90) and slight dependence or independence for basic ADL (BI 91-100). We compared their baseline characteristics and used logistic regression models to determine whether a BI≤60 confers higher one-year mortality risk.

RESULTS

We included 2195 patients, mean age 83years; 57% women, Charlson Index 3, 65% with preserved left ventricular ejection fraction. Their median preadmission BI was 90 (65-100); 21.7% had BI≤60. Patients with BI≤60 were older, more often females, with higher comorbid and cognitive burden and more likely to be institutionalized. 560 patients (26%) died within the follow-up period. A preadmission BI≤60 was significantly associated with higher risk of 12-month mortality (HR 1.42, 95% CI 1.14-1.77) together with male sex (1.27, 1.04-1.54), valve disease (1.49, 1.20-1.83), worse preadmission NYHA class (1.44, 1.20-1.73), stage IV chronic kidney disease (1.70, 1.35-2.15), pulmonary edema (1.33, 1.01-1.76), no family support (1.47, 1.06-2.06), and higher Charlson Comorbidity Index (1.09, CI 1.05-1.13) and Pfeiffer cognitive screening questionnaire scores (1.10, 1.05-1.14).

CONCLUSION

Among elderly AHF patients, the presence of severe (BI≤60) preadmission dependence for basic ADL confers a significant and independent risk of one-year post-discharge mortality.

P2X7 Receptor and APOE Polymorphisms and Survival from Heart Failure: A Prospective Study in Frail Patients in a Geriatric Unit

Heart failure (HF) is one of the most frequent cause of hospitalization in elderly and often coexists with concurrent geriatric syndromes, like cognitive disturbances; various pathophysiological mechanisms are shared by HF and cognitive decline, notably a substrate of low-grade inflammation. We investigated whether SNPs in the purinergic receptor (P2X7R) and apolipoprotein (APO) E genes, both involved in a series of inflammatory responses, are associated to HF or cognitive impairment and are able to predict post-discharge mortality in the elderly. We prospectively analyzed 198 patients (age 85 ± 8 years, predominantly females) admitted to a Geriatric unit for acute HF, whose diagnosis was based on clinical signs, brain natriuretic peptide (BNP) values and ecocardiography in uncertain diagnosis (BNP values between 100 and 400 pg/mL); cognitive performance was assesed by Short Portable Mental Status Questionnaire (SPMSQ). In all the participants, SNPs rs208294 and rs3751143 for P2X7R gene and rs429558 and rs7412 for APOE gene were assessed. Information on all-cause mortality was adjudicated by medical records review 36 months after discharge. We found no relationship between P2X7R and APOE polymorphisms and 36-month post-discharge mortality; a better outcome for overall survival was observed in patients with BNP values below the median (281 pg/mL) (p=0.002) persisting after adjustment for renal function and age, and in those with cognitive impairment (p<0.001). Patients harboring APOE-ε4 genotype showed higher BNP concentrations than noncarriers (1289.9 ± 226.9 vs 580.5 ± 90.2 pg/mL respectively,p=0.004), whereas none of the studied SNPs were associated to impairment in cognitive performance. In conclusion, neither P2X7R or APOE genotype seem to predict long-term mortality in elderly patients. Interestingly, APOE-ε4 genotype was associated to higher BNP values, suggesting a putative interaction between genetic and biochemical markers in identifying people at risk for HF.

Chronic Heart Failure Care Planning: Considerations in Older Patients

In developed countries, it is estimated that more than 10 % of adults aged over 70 years have heart failure (HF). Despite therapeutic advances, it remains a condition associated with significant morbidity and mortality. It is one of the commonest causes of unscheduled hospital admissions in older adults and data consistently show a lower uptake of evidence-based investigations and therapies as well as higher rates of HF hospitalisations and mortality than in younger adults. These rates are highest amongst patients discharged to 'skilled nursing facilities', where comorbidities, frailty and cognitive impairment are common and have a significant impact on outcomes. In this review, we examine current guidance and its limitations and offer a pragmatic approach to management of HF in this elderly population.

The frailty syndrome is associated with adverse health outcomes in very old patients with stable heart failure: A prospective study in six Spanish hospitals

BACKGROUND

Most studies on the association between the frailty syndrome and adverse health outcomes in patients with heart failure (HF) have used non-standard definitions of frailty. This study examined the association of frailty, diagnosed by well-accepted criteria, with mortality, readmission and functional decline in very old ambulatory patients with HF.

METHODS

Prospective study with 497 patients in six Spanish hospitals and followed up during one year. Mean (SD) age was 85.2 (7.3) years, and 79.3% had LVEF >45%. Frailty was diagnosed as having ≥3 of the 5 Fried criteria. Readmission was defined as a new episode of hospitalisation lasting >24h, and functional decline as an incident limitation in any activity of daily living at the 1-year visit. Statistical analyses were performed with Cox and logistic regression, as appropriate, and adjusted for the main prognostic factors at baseline.

RESULTS

At baseline, 57.5% of patients were frail. The adjusted hazard ratio (95% confidence interval) for mortality among frail versus non-frail patients was 1.93 (1.20-3.27). Mortality was higher among patients with low physical activity [1.64 (1.10-2.45)] or exhaustion [1.83 (1.21-2.77)]. Frailty was linked to increased risk of readmission [1.66 (1.17-2.36)] and functional decline [odds ratio 1.67 (1.01-2.79)]. Slow gait speed was related to functional decline [odds ratio 3.59 (1.75-7.34)]. A higher number of frailty criteria was associated with a higher risk of the three study outcomes (P trend<0.01 in each outcome).

CONCLUSIONS

Frailty was associated with increased risk of 1-year mortality, hospital readmission and functional decline among older ambulatory patients with HF.

Practical approach on frail older patients attended for acute heart failure

Acute heart failure (AHF) is a multi-organ dysfunction syndrome. In addition to known cardiac dysfunction, non-cardiac comorbidity, frailty and disability are independent risk factors of mortality, morbidity, cognitive and functional decline, and risk of institutionalization. Frailty, a treatable and potential reversible syndrome very common in older patients with AHF, increases the risk of disability and other adverse health outcomes. This position paper highlights the need to identify frailty in order to improve prognosis, the risk-benefits of invasive diagnostic and therapeutic procedures, and the definition of older-person-centered and integrated care plans.

Heart Failure in Older Adults

Heart failure (HF) is a leading cause of morbidity, hospitalization, and mortality in older adults and a growing public health problem placing a huge financial burden on the health care system. Many challenges exist in the assessment and management of HF in geriatric patients, who often have coexisting multimorbidity, polypharmacy, cognitive impairment, and frailty. These complex "geriatric domains" greatly affect physical and functional status as well as long-term clinical outcomes. Geriatric patients have been under-represented in major HF clinical trials. Nonetheless, available data suggest that guideline-based medical and device therapies improve morbidity and mortality. Nonpharmacologic strategies, such as exercise training and dietary interventions, are an active area of research. Targeted geriatric evaluation, including functional and cognitive assessment, can improve risk stratification and guide management in older patients with HF. Clinical trials that enroll older patients with multiple morbidities and HF and evaluate functional status and quality of life in addition to mortality and cardiovascular morbidity should be encouraged to guide management of this age group.

[Prognostic value of the primary diagnosis in elderly patients admitted to an acute geriatric unit at discharge and one year later]

OBJECTIVE

To analyse the relationship between the primary diagnosis on admission to an Acute Geriatric Unit (AGU) and the risk of hospital mortality and one year after discharge

MATERIAL AND METHODS

A longitudinal study was conducted on patients admitted to the Central Hospital AGU Red Cross in Madrid in 2009. The admission diagnosis was grouped by Diagnosis Related Groups (DRGs). The date of death was collected from the medical charts and the National Death Index Ministry of Health report. The main outcome of study was the association between diagnoses on admission and functional impairment at discharge (measured as a loss of 10 or more points between the Barthel Index at discharge and that on admission), mortality during hospitalization, at 3 months and one year after discharge. The multivariate analysis was adjusted for age, sex, comorbidity, functional and cognitive status, and serum albumin.

RESULTS

The study included1147 patients, with a mean age of 86.7 years (SD±6.7), and 66% were women. During admission, 10.1% of patients died and 36.6% had functional impairment at discharge. After discharge, 25.5% died at 3 months, and 42.2% at one year. The distribution of the primary diagnoses at admission (between parentheses hospital mortality and at year) were heart failure, 21.4% (8.1% and 37.4%), pneumonia,13.3% (12.3% and 46.4%), and aspiration pneumonia, 4.7% (27.5%, y 71%), respiratory diseases,13.3% (6.6% and 38.2%), urinary infection,10.2% (5.1% and 42.7%), and stroke (excluding AIT), 9.9% (13.3% and 46.9%). In the multivariate analysis, only admissions due to aspiration pneumonia were independently associated with increased risk of hospital mortality (odds ratio, 2.23; 95% CI=1.13 to 44.42), and stroke with increased risk of functional impairment at discharge (odds ratio, 6.01; 95% CI=3.42-10.57). No diagnosis was independently associated with increased risk of death at 3 months and at year

CONCLUSIONS

Admission from aspiration pneumonia carries an increased risk of death in elderly patients hospitalised for acute medical conditions. After discharge, the risk of death must be attributed to factors other than the admission diagnosis.

[Chronic heart failure in the elderly patient]

The prevalence and incidence of heart failure (HF) is increasing, especially in the elderly population, and is becoming a major geriatric problem. Elderly patients with HF usually show etiopathogenic, epidemiological, and even clinical characteristics significantly different from those present in younger patients. Their treatment, however, derives from clinical trials performed with only a few elderly subjects. Moreover, beyond the cardiovascular disease itself, it is essential to evaluate the patient as a whole, given the interrelationship between HF and the characteristic geriatric syndromes of the elderly patient. This review examines the peculiarities in the most prevalent "real world" HF patient.

Transitions of care in heart failure: a scientific statement from the American Heart Association

In patients with heart failure (HF), use of 30-day rehospitalization as a healthcare metric and increased pressure to provide value-based care compel healthcare providers to improve efficiency and to use an integrated care approach. Transition programs are being used to achieve goals. Transition of care in the context of HF management refers to individual interventions and programs with multiple activities that are designed to improve shifts or transitions from one setting to the next, most often from hospital to home. As transitional care programs become the new normal for patients with chronic HF, it is important to understand the current state of the science of transitional care, as discussed in the available research literature. Of transitional care reports, there was much heterogeneity in research designs, methods, study aims, and program targets, or they were not well described. Often, programs used bundled interventions, making it difficult to discuss the efficiency and effectiveness of specific interventions. Thus, further HF transition care research is needed to ensure best practices related to economically and clinically effective and feasible transition interventions that can be broadly applicable. This statement provides an overview of the complexity of HF management and includes patient, hospital, and healthcare provider barriers to understanding end points that best reflect clinical benefits and to achieving optimal clinical outcomes. The statement describes transitional care interventions and outcomes and discusses implications and recommendations for research and clinical practice to enhance patient-centered outcomes.

Comprehensive geriatric assessment predicts mortality and adverse outcomes in hospitalized older adults

Background

Comprehensive Geriatric Assessment (CGA) provides detailed information on clinical, functional and cognitive aspects of older patients and is especially useful for assessing frail individuals. Although a large proportion of hospitalized older adults demonstrate a high level of complexity, CGA was not developed specifically for this setting. Our aim was to evaluate the application of a CGA model for the clinical characterization and prognostic prediction of hospitalized older adults.

Methods

This was a prospective observational study including 746 patients aged 60 years and over who were admitted to a geriatric ward of a university hospital between January 2009 and December 2011, in Sao Paulo, Brazil. The proposed CGA was applied to evaluate all patients at admission. The primary outcome was in-hospital death, and the secondary outcomes were delirium, nosocomial infections, functional decline and length of stay. Multivariate binary logistic regression was performed to assess independent factors associated with these outcomes, including socio-demographic, clinical, functional, cognitive, and laboratory variables. Impairment in ten CGA components was particularly investigated: polypharmacy, activities of daily living (ADL) dependency, instrumental activities of daily living (IADL) dependency, depression, dementia, delirium, urinary incontinence, falls, malnutrition, and poor social support.

Results

The studied patients were mostly women (67.4%), and the mean age was 80.5±7.9 years. Multivariate logistic regression analysis revealed the following independent factors associated with in-hospital death: IADL dependency (OR=4.02; CI=1.52-10.58; p=.005); ADL dependency (OR=2.39; CI=1.25-4.56; p=.008); malnutrition (OR=2.80; CI=1.63-4.83; p<.001); poor social support (OR=5.42; CI=2.93-11.36; p<.001); acute kidney injury (OR=3.05; CI=1.78-5.27; p<.001); and the presence of pressure ulcers (OR=2.29; CI=1.04-5.07; p=.041). ADL dependency was independently associated with both delirium incidence and nosocomial infections (respectively: OR=3.78; CI=2.30-6.20; p<.001 and OR=2.30; CI=1.49-3.49; p<.001). The number of impaired CGA components was also found to be associated with in-hospital death (p<.001), delirium incidence (p<.001) and nosocomial infections (p=.005). Additionally, IADL dependency, malnutrition and history of falls predicted longer hospitalizations. There were no significant changes in overall functional status during the hospital stay.

Conclusions

CGA identified patients at higher risk of in-hospital death and adverse outcomes, of which those with functional dependence, malnutrition and poor social support were foremost.