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Trochez RJ, Barrett JB, Shi Y, Schildcrout JS, Rick C, Nair D, Welch SA, Kumar AA, Bell SP, Kripalani S. Vulnerability to functional decline is associated with noncardiovascular cause of 90-day readmission in hospitalized patients with heart failure. J Hosp Med 2024; 19:386-393. [PMID: 38402406 DOI: 10.1002/jhm.13316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 01/29/2024] [Accepted: 02/05/2024] [Indexed: 02/26/2024]
Abstract
BACKGROUND Hospital readmission is common among patients with heart failure. Vulnerability to decline in physical function may increase the risk of noncardiovascular readmission for these patients, but the association between vulnerability and the cause of unplanned readmission is poorly understood, inhibiting the development of effective interventions. OBJECTIVES We examined the association of vulnerability with the cause of readmission (cardiovascular vs. noncardiovascular) among hospitalized patients with acute decompensated heart failure. DESIGNS, SETTINGS, AND PARTICIPANTS This prospective longitudinal study is part of the Vanderbilt Inpatient Cohort Study. MAIN OUTCOME AND MEASURES The primary outcome was the cause of unplanned readmission (cardiovascular vs. noncardiovascular). The primary independent variable was vulnerability, measured using the Vulnerable Elders Survey (VES-13). RESULTS Among 804 hospitalized patients with acute decompensated heart failure, 315 (39.2%) experienced an unplanned readmission within 90 days of discharge. In a multinomial logistic model with no readmission as the reference category, higher vulnerability was associated with readmission for noncardiovascular causes (relative risk ratio [RRR] = 1.36, 95% confidence interval [CI]: 1.06-1.75) in the first 90 days after discharge. The VES-13 score was not associated with readmission for cardiovascular causes (RRR = 0.94, 95% CI: 0.75-1.17). CONCLUSIONS Vulnerability to functional decline predicted noncardiovascular readmission risk among hospitalized patients with heart failure. The VES-13 is a brief, validated, and freely available tool that should be considered in planning care transitions. Additional work is needed to examine the efficacy of interventions to monitor and mitigate noncardiovascular concerns among vulnerable patients with heart failure being discharged from the hospital.
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Affiliation(s)
- Ricardo J Trochez
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jennifer B Barrett
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Yaping Shi
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jonathan S Schildcrout
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Chelsea Rick
- Department of Medicine, Division of Geriatric Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Devika Nair
- Department of Medicine, Division of Nephrology & Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sarah A Welch
- Department of Physical Medicine & Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Veterans Affairs, Geriatric Research Education and Clinical Center(GRECC), Tennessee Valley Healthcare System, Nashville, Tennessee, USA
| | - Anupam A Kumar
- Department of Medicine, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Susan P Bell
- Department of Medicine, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sunil Kripalani
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Section of Hospital Medicine, Department of Medicine, Division of General Internal Medicine & Public Health, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Nair D, Schildcrout JS, Shi Y, Trochez R, Nwosu S, Bell SP, Mixon AS, Welch SA, Goggins K, Bachmann JM, Vasilevskis EE, Cavanaugh KL, Rothman RL, Kripalani SB. Patient-reported predictors of postdischarge mortality after cardiac hospitalization. J Hosp Med 2024. [PMID: 38560772 DOI: 10.1002/jhm.13336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Revised: 03/07/2024] [Accepted: 03/09/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND Adults hospitalized for cardiovascular events are at high risk for postdischarge mortality. Screening of psychosocial risk is prioritized by the Joint Commission. We tested whether key patient-reported psychosocial and behavioral measures could predict posthospitalization mortality in a cohort of adults hospitalized for a cardiovascular event. METHODS We conducted a prospective cohort study to test the prognostic utility of validated patient-reported measures, including health literacy, social support, health behaviors and disease management, and socioeconomic status. Cox survival analyses of mortality were conducted over a median of 3.5 years. RESULTS Among 2977 adults hospitalized for either acute coronary syndrome or acute decompensated heart failure, the mean age was 53 years, and 60% were male. After adjusting for demographic, clinical, and other psychosocial factors, mortality risk was greatest among patients who reported being unemployed (hazard ratio [HR]: 1.99, 95% confidence interval [CI]): 1.30-3.06), retired (HR: 2.14, 95% CI: 1.60-2.87), or unable to work due to disability (HR: 2.36, 95% CI: 1.73-3.21), as compared to those who were employed. Patient-reported perceived health competence (PHCS-2) and exercise frequency were also associated with mortality risk after adjusting for all other variables (HR: 0.86, 95% CI: 0.73-1.00 per four-point increase in PHCS-2; HR: 0.86, 95% CI: 0.77-0.96 per 3-day increase in exercise frequency, respectively). CONCLUSIONS Patient-reported measures of employment status, perceived health competence, and exercise frequency independently predict mortality after a cardiac hospitalization. Incorporating these brief, valid measures into hospital-based screening may help with prognostication and targeting patients for resources during post-discharge transitions of care.
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Affiliation(s)
- Devika Nair
- Department of Medicine, Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Vanderbilt Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jonathan S Schildcrout
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Yaping Shi
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Ricardo Trochez
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sam Nwosu
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Susan P Bell
- Department of Medicine, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Amanda S Mixon
- Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Veterans Affairs, Geriatric Research Education and Clinical Center (GRECC), Tennessee Valley Healthcare System, Nashville, Tennessee, USA
| | - Sarah A Welch
- Department of Veterans Affairs, Geriatric Research Education and Clinical Center (GRECC), Tennessee Valley Healthcare System, Nashville, Tennessee, USA
- Department of Physical Medicine and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kathryn Goggins
- Vanderbilt Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Justin M Bachmann
- Department of Medicine, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | - Kerri L Cavanaugh
- Department of Medicine, Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Vanderbilt Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Russell L Rothman
- Institute of Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sunil B Kripalani
- Vanderbilt Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Center for Clinical Quality and Implementation Research, VUMC, Nashville, Tennessee, USA
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Nair D, Schildcrout JS, Shi Y, Trochez R, Nwosu S, Bell SP, Mixon AS, Welch SA, Goggins K, Bachmann JM, Vasilevskis EE, Cavanaugh KL, Rothman RL, Kripalani SB. Patient-reported predictors of post-discharge mortality after cardiac hospitalization. medRxiv 2023:2023.10.02.23296460. [PMID: 37873096 PMCID: PMC10593012 DOI: 10.1101/2023.10.02.23296460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
Background Adults hospitalized for cardiovascular events are at high risk for post-discharge mortality. Hospital-based screening of health-related psychosocial risk factors is now prioritized by the Joint Commission and the National Quality Forum to achieve equitable, high-quality care. We tested our hypothesis that key patient-reported psychosocial and behavioral measures could predict post-hospitalization mortality in a cohort of adults hospitalized for a cardiovascular event. Methods This was a prospective cohort of adults hospitalized at Vanderbilt University Medical Center. Validated patient-reported measures of health literacy, social support, disease self-management, and socioeconomic status were used as predictors of interest. Cox survival analyses of mortality were conducted over a median 3.5-year follow-up (range: 1.25 - 5.5 years). Results Among 2,977 adults, 1,874 (63%) were hospitalized for acute coronary syndrome and 1,103 (37%) were hospitalized for acute decompensated heart failure; 60% were male; and the mean age was 53 years. After adjusting for demographic, clinical, and other psychosocial factors, mortality risk was greatest among patients who reported being unable to work due to disability (Hazard Ratio (HR) 2.36, 95% Confidence Interval (CI): 1.73-3.21), who were retired (HR 2.14, 95% CI 1.60-2.87), and who reported unemployment (HR 1.99, 95% CI 1.30-3.06) as compared to those who were employed. Patient-reported measures of disease self-management, perceived health competence and exercise frequency, were also associated with mortality risk after full covariate adjustment (HR 0.86, 95% CI 0.73-1.00 per four-point increase), (HR 0.86, 95% CI 0.77-0.96 per three-day change), respectively. Conclusions Patient-reported measures of employment status independently predict post-discharge mortality after a cardiac hospitalization. Measure of disease self-management also have prognostic modest utility. Hospital-based screening of psychosocial risk is increasingly prioritized in legislative policy. Incorporating brief, valid measures of employment status and disease self-management factors may help target patients for psychosocial, financial, and rehabilitative resources during post-discharge transitions of care.
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El-Sabawi B, Cloud H, Patel JN, Bell SP, Elmariah S, Fearon WF, Kim JB, Piana RN, Kapadia SR, Kumbhani DJ, Gillam LD, Whisenant BK, Quader N, Zajarias A, Welt FG, Bavry AA, Coylewright M, Vatterott A, Jackson N, Huang S, Lindman BR. Association of Depression and Cognitive Dysfunction With Patient-Centered Outcomes After Transcatheter Aortic Valve Replacement. Circ Cardiovasc Interv 2023; 16:e012875. [PMID: 37503662 DOI: 10.1161/circinterventions.123.012875] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 07/05/2023] [Indexed: 07/29/2023]
Abstract
BACKGROUND Depression and cognitive dysfunction (CD) are not routinely screened for in patients before transcatheter aortic valve replacement (TAVR) and their association with postprocedural outcomes is poorly understood. The objectives of this study are to determine the prevalence of depression and CD in patients with aortic stenosis undergoing TAVR and evaluate their association with mortality and quality of life. METHODS We analyzed a prospective, multicenter TAVR registry that systematically screened patients for preexisting depression and CD with the Patient Health Questionnaire-2 and Mini-Cog, respectively. The associations with mortality were assessed with Cox proportional hazard models and quality of life (Kansas City Cardiomyopathy Questionnaire and EuroQol visual analogue scale) were evaluated using multivariable ordinal regression models. RESULTS A total of 884 patients were included; median follow-up was 2.88 years (interquartile range=1.2-3.7). At baseline, depression was observed in 19.6% and CD in 31.8%. In separate models, after adjustment, depression (HR, 1.45 [95% CI, 1.13-1.86]; P<0.01) and CD (HR, 1.27 [95% CI, 1.02-1.59]; P=0.04) were each associated with increased mortality. Combining depression and CD into a single model, mortality was greatest among those with both depression and CD (n=62; HR, 2.06 [CI, 1.44-2.96]; P<0.01). After adjustment, depression was associated with 6.6 (0.3-13.6) points lower on the Kansas City Cardiomyopathy Questionnaire 1-year post-TAVR and 6.7 (0.5-12.7) points lower on the EuroQol visual analogue scale. CD was only associated with lower EuroQol visual analogue scale. CONCLUSIONS Depression and CD are common in patients that undergo TAVR and are associated with increased mortality and worse quality of life. Depression may be a modifiable therapeutic target to improve outcomes after TAVR.
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Affiliation(s)
- Bassim El-Sabawi
- Department of Medicine, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN (B.E.-S., H.C., J.N.P., S.P.B., R.N.P., A.V., N.J., B.R.L.)
| | - Harrison Cloud
- Department of Medicine, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN (B.E.-S., H.C., J.N.P., S.P.B., R.N.P., A.V., N.J., B.R.L.)
| | - Jay N Patel
- Department of Medicine, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN (B.E.-S., H.C., J.N.P., S.P.B., R.N.P., A.V., N.J., B.R.L.)
| | - Susan P Bell
- Department of Medicine, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN (B.E.-S., H.C., J.N.P., S.P.B., R.N.P., A.V., N.J., B.R.L.)
| | - Sammy Elmariah
- Department of Medicine, Division of Cardiology, University of California San Francisco (S.E.)
| | - William F Fearon
- Department of Medicine, Division of Cardiology, Stanford Medical Center, Palo Alto, CA (W.F.F., J.B.K.)
| | - Juyong B Kim
- Department of Medicine, Division of Cardiology, Stanford Medical Center, Palo Alto, CA (W.F.F., J.B.K.)
| | - Robert N Piana
- Department of Medicine, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN (B.E.-S., H.C., J.N.P., S.P.B., R.N.P., A.V., N.J., B.R.L.)
| | - Samir R Kapadia
- Department of Medicine, Division of Cardiology, Cleveland Clinic Foundation, OH (S.R.K.)
| | - Dharam J Kumbhani
- Department of Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (D.J.K., A.A.B.)
| | - Linda D Gillam
- Department of Cardiovascular Medicine, Morristown Medical Center, NJ (L.D.G.)
| | - Brian K Whisenant
- Department of Medicine, Division of Cardiology, Intermountain Heart Institute, Murray, UT (B.K.W.)
| | - Nishath Quader
- Department of Medicine, Division of Cardiology, Barnes-Jewish Hospital, St Louis, MO (N.Q., A.Z.)
| | - Alan Zajarias
- Department of Medicine, Division of Cardiology, Barnes-Jewish Hospital, St Louis, MO (N.Q., A.Z.)
| | - Frederick G Welt
- Department of Medicine, Division of Cardiology, University of Utah Hospital, Salt Lake City (F.G.W.)
| | - Anthony A Bavry
- Department of Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (D.J.K., A.A.B.)
| | - Megan Coylewright
- Department of Internal Medicine, Division of Cardiovascular Medicine, Erlanger Heart and Lung Institute, Chattanooga, TN (M.C.)
| | - Anna Vatterott
- Department of Medicine, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN (B.E.-S., H.C., J.N.P., S.P.B., R.N.P., A.V., N.J., B.R.L.)
| | - Natalie Jackson
- Department of Medicine, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN (B.E.-S., H.C., J.N.P., S.P.B., R.N.P., A.V., N.J., B.R.L.)
- Structural Heart and Valve Center, Vanderbilt University Medical Center, Nashville, TN (N.J., B.R.L.)
| | - Shi Huang
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN (S.H.)
| | - Brian R Lindman
- Department of Medicine, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN (B.E.-S., H.C., J.N.P., S.P.B., R.N.P., A.V., N.J., B.R.L.)
- Structural Heart and Valve Center, Vanderbilt University Medical Center, Nashville, TN (N.J., B.R.L.)
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Moore EE, Khan OA, Shashikumar N, Pechman KR, Liu D, Bell SP, Nair S, Terry JG, Gifford KA, Anderson AW, Landman BA, Blennow K, Zetterberg H, Hohman TJ, Carr JJ, Jefferson AL. Axonal Injury Partially Mediates Associations Between Increased Left Ventricular Mass Index and White Matter Damage. Stroke 2022; 53:808-816. [PMID: 34702069 PMCID: PMC8885768 DOI: 10.1161/strokeaha.121.034349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND PURPOSE Left ventricular (LV) mass index is a marker of subclinical LV remodeling that relates to white matter damage in aging, but molecular pathways underlying this association are unknown. This study assessed if LV mass index related to cerebrospinal fluid (CSF) biomarkers of microglial activation (sTREM2 [soluble triggering receptor expressed on myeloid cells 2]), axonal injury (NFL [neurofilament light]), neurodegeneration (total-tau), and amyloid-β, and whether these biomarkers partially accounted for associations between increased LV mass index and white matter damage. We hypothesized higher LV mass index would relate to greater CSF biomarker levels, and these pathologies would partially mediate associations with cerebral white matter microstructure. METHODS Vanderbilt Memory and Aging Project participants who underwent cardiac magnetic resonance, lumbar puncture, and diffusion tensor imaging (n=142, 72±6 years, 37% mild cognitive impairment [MCI], 32% APOE-ε4 positive, LV mass index 51.4±8.1 g/m2, NFL 1070±588 pg/mL) were included. Linear regressions and voxel-wise analyses related LV mass index to each biomarker and diffusion tensor imaging metrics, respectively. Follow-up models assessed interactions with MCI and APOE-ε4. In models where LV mass index significantly related to a biomarker and white matter microstructure, we assessed if the biomarker mediated white matter associations. RESULTS Among all participants, LV mass index was unrelated to CSF biomarkers (P>0.33). LV mass index interacted with MCI (P=0.01), such that higher LV mass index related to increased NFL among MCI participants. Associations were also present among APOE-ε4 carriers (P=0.02). NFL partially mediated up to 13% of the effect of increased LV mass index on white matter damage. CONCLUSIONS Subclinical cardiovascular remodeling, measured as an increase in LV mass index, is associated with neuroaxonal degeneration among individuals with MCI and APOE-ε4. Neuroaxonal degeneration partially reflects associations between higher LV mass index and white matter damage. Findings highlight neuroaxonal degeneration, rather than amyloidosis or microglia, may be more relevant in pathways between structural cardiovascular remodeling and white matter damage.
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Affiliation(s)
- Elizabeth E. Moore
- Vanderbilt Memory & Alzheimer’s Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Omair A. Khan
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Niranjana Shashikumar
- Vanderbilt Memory & Alzheimer’s Center, Vanderbilt University Medical Center, Nashville, TN, USA,Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kimberly R. Pechman
- Vanderbilt Memory & Alzheimer’s Center, Vanderbilt University Medical Center, Nashville, TN, USA,Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Dandan Liu
- Vanderbilt Memory & Alzheimer’s Center, Vanderbilt University Medical Center, Nashville, TN, USA,Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Susan P. Bell
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sangeeta Nair
- Department of Radiology & Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, USA
| | - James G. Terry
- Department of Radiology & Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Katherine A. Gifford
- Vanderbilt Memory & Alzheimer’s Center, Vanderbilt University Medical Center, Nashville, TN, USA,Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Adam W. Anderson
- Department of Biomedical Engineering, Vanderbilt University, Nashville, TN, USA
| | - Bennett A. Landman
- Department of Radiology & Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, USA,Department of Biomedical Engineering, Vanderbilt University, Nashville, TN, USA,Department of Electrical Engineering and Computer Science, Vanderbilt University, Nashville, TN, USA
| | - Kaj Blennow
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at University of Gothenburg, Mölndal, Sweden,Clinical Neurochemistry Lab, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at University of Gothenburg, Mölndal, Sweden,Clinical Neurochemistry Lab, Sahlgrenska University Hospital, Mölndal, Sweden,Department of Neurodegenerative Disease, University of College London Institute of Neurology, Queen Square, London, UK,United Kingdom Dementia Research Institute at University College London, London, UK
| | - Timothy J. Hohman
- Vanderbilt Memory & Alzheimer’s Center, Vanderbilt University Medical Center, Nashville, TN, USA,Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA,Vanderbilt Genetics Institute, Vanderbilt University Medical Center, Nashville, TN, USA
| | - John Jeffrey Carr
- Department of Radiology & Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Angela L. Jefferson
- Vanderbilt Memory & Alzheimer’s Center, Vanderbilt University Medical Center, Nashville, TN, USA,Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA,Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
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Abstract
It is well known that cardiovascular disease manifests differently in women and men. The underlying causes of these differences during the aging lifespan are less well understood. Sex differences in cardiac and vascular phenotypes are seen in childhood and tend to track along distinct trajectories related to dimorphism in genetic factors as well as response to risk exposures and hormonal changes during the life course. These differences underlie sex-specific variation in cardiovascular events later in life, including myocardial infarction, heart failure, ischemic stroke, and peripheral vascular disease. With respect to cardiac phenotypes, females have intrinsically smaller body size-adjusted cardiac volumes and they tend to experience greater age-related wall thickening and myocardial stiffening with aging. With respect to vascular phenotypes, sexual dimorphism in both physiology and pathophysiology are also seen, including overt differences in blood pressure trajectories. The majority of sex differences in myocardial and vascular alterations that manifest with aging seem to follow relatively consistent trajectories from the very early to the very later stages of life. This review aims to synthesize recent cardiovascular aging-related research to highlight clinically relevant studies in diverse female and male populations that can inform approaches to improving the diagnosis, management, and prognosis of cardiovascular disease risks in the aging population at large.
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Affiliation(s)
- Hongwei Ji
- Department of Cardiology, the Affiliated Hospital of Qingdao University, Qingdao, Shandong, China,Department of Cardiology, Shanghai Tenth People’s Hospital, Tongji University, Shanghai, China
| | - Alan C. Kwan
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Melanie Chen
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - David Ouyang
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Joseph E. Ebinger
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Susan P. Bell
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Teemu Niiranen
- Department of Internal Medicine, University of Turku, Turku, Finland,Department of Public Health Solutions, Finnish Institute for Health and Welfare, Turku, Finland
| | - Natalie A. Bello
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Susan Cheng
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Moore EE, Shashikumar N, Pechman KR, Bell SP, Gifford KA, Landman BA, Blennow K, Zetterberg H, Hohman TJ, Jefferson AL. Comparison of the prognostic value of cerebrospinal fluid and plasma neurofilament light in predicting longitudinal decline in white matter integrity among older adults. Alzheimers Dement 2021. [DOI: 10.1002/alz.054958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Elizabeth E. Moore
- Vanderbilt University Medical Center Nashville TN USA
- Vanderbilt Memory & Alzheimer's Center, Vanderbilt University Medical Center Nashville TN USA
| | - Niranjana Shashikumar
- Vanderbilt University Medical Center Nashville TN USA
- Vanderbilt Memory & Alzheimer's Center, Vanderbilt University Medical Center Nashville TN USA
| | - Kimberly R. Pechman
- Vanderbilt University Medical Center Nashville TN USA
- Vanderbilt Memory & Alzheimer’s Center, Department of Neurology, Vanderbilt University Medical Center Nashville TN USA
| | - Susan P. Bell
- Vanderbilt University Medical Center Nashville TN USA
| | - Katherine A. Gifford
- Vanderbilt University Medical Center Nashville TN USA
- Vanderbilt Memory & Alzheimer’s Center, Department of Neurology, Vanderbilt University Medical Center Nashville TN USA
| | | | - Kaj Blennow
- Institute of Neuroscience and Physiology, Sahlgrenska Academy at the University of Gothenburg Mölndal Sweden
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital Mölndal Sweden
| | - Henrik Zetterberg
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital Mölndal Sweden
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, University of Gothenburg Mölndal Sweden
- UK Dementia Research Institute Fluid Biomarkers Laboratory, UK DRI at UCL London United Kingdom
- Department of Neurodegenerative Disease, UCL Queen Square Institute of Neurology London United Kingdom
| | - Timothy J. Hohman
- Vanderbilt Genetics Institute, Vanderbilt University Medical Center Nashville TN USA
| | - Angela L. Jefferson
- Vanderbilt University Medical Center Nashville TN USA
- Vanderbilt Genetics Institute, Vanderbilt University Medical Center Nashville TN USA
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8
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Moore EE, Liu D, Li J, Schimmel SJ, Cambronero FE, Terry JG, Nair S, Pechman KR, Moore ME, Bell SP, Beckman JA, Gifford KA, Hohman TJ, Blennow K, Zetterberg H, Carr JJ, Jefferson AL. Association of Aortic Stiffness With Biomarkers of Neuroinflammation, Synaptic Dysfunction, and Neurodegeneration. Neurology 2021; 97:e329-e340. [PMID: 34031194 PMCID: PMC8362359 DOI: 10.1212/wnl.0000000000012257] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 04/21/2021] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVES To test the hypothesis that increased aortic stiffening is associated with greater CSF evidence of core Alzheimer disease pathology (β-amyloid [Aβ], phosphorylated tau [p-tau]), neurodegeneration (total tau [t-tau]), synaptic dysfunction (neurogranin), neuroaxonal injury (neurofilament light [NFL]), and neuroinflammation (YKL-40, soluble triggering receptor expressed on myeloid cells 2 [sTREM2]), we analyzed pulse wave velocity (PWV) data and CSF data among older adults. METHODS Participants free of stroke and dementia from the Vanderbilt Memory and Aging Project, an observational community-based study, underwent cardiac magnetic resonance to assess aortic PWV (meters per second) and lumbar puncture to obtain CSF. Linear regressions related aortic PWV to CSF Aβ, p-tau, t-tau, neurogranin, NFL, YKL-40, and sTREM2 concentrations after adjustment for age, race/ethnicity, education, apolipoprotein (APOE) ε4 status, Framingham Stroke Risk Profile, and cognitive diagnosis. Models were repeated testing PWV interactions with age, diagnosis, APOE ε4, and hypertension on each biomarker. RESULTS One hundred forty-six participants were examined (age 72 ± 6 years). Aortic PWV interacted with age on p-tau (β = 0.31, p = 0.04), t-tau, (β = 2.67, p = 0.05), neurogranin (β = 0.94, p = 0.04), and sTREM2 (β = 20.4, p = 0.05). Among participants >73 years of age, higher aortic PWV related to higher p-tau (β = 2.4, p = 0.03), t-tau (β = 19.3, p = 0.05), neurogranin (β = 8.4, p = 0.01), and YKL-40 concentrations (β = 7,880, p = 0.005). Aortic PWV had modest interactions with diagnosis on neurogranin (β = -10.76, p = 0.03) and hypertension status on YKL-40 (β = 18,020, p < 0.001). CONCLUSIONS Among our oldest participants, ≥74 years of age, greater aortic stiffening is associated with in vivo biomarker evidence of neuroinflammation, tau phosphorylation, synaptic dysfunction, and neurodegeneration, but not amyloidosis. Central arterial stiffening may lead to cumulative cerebral microcirculatory damage and reduced blood flow delivery to tissue, resulting in neuroinflammation and neurodegeneration in more advanced age.
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Affiliation(s)
- Elizabeth E Moore
- From the Vanderbilt Memory & Alzheimer's Center (E.E.M., D.L., J.L., S.J.S., F.E.C., K.R.P., M.E.M., K.A.G., T.J.H., A.L.J.), Department of Biostatistics (D.L.), Radiology & Radiological Sciences (J.G.T., S.N., J.J.C.), Department of Neurology (K.R.P., M.E.M., K.A.G., T.J.H., A.L.J.), Division of Cardiovascular Medicine (S.P.B., J.A.B., A.L.J.), Department of Medicine, and Vanderbilt Genetics Institute (T.J.H.), Vanderbilt University Medical Center, Nashville, TN; Department of Psychiatry and Neurochemistry (K.B., H.Z.), Institute of Neuroscience and Physiology, The Sahlgrenska Academy at University of Gothenburg; Clinical Neurochemistry Laboratory (K.B., H.Z.), Sahlgrenska University Hospital, Molndal, Sweden; Department of Neurodegenerative Disease (H.Z.), University College London Institute of Neurology, Queen Square; and United Kingdom Dementia Research Institute at University College London (H.Z.), UK
| | - Dandan Liu
- From the Vanderbilt Memory & Alzheimer's Center (E.E.M., D.L., J.L., S.J.S., F.E.C., K.R.P., M.E.M., K.A.G., T.J.H., A.L.J.), Department of Biostatistics (D.L.), Radiology & Radiological Sciences (J.G.T., S.N., J.J.C.), Department of Neurology (K.R.P., M.E.M., K.A.G., T.J.H., A.L.J.), Division of Cardiovascular Medicine (S.P.B., J.A.B., A.L.J.), Department of Medicine, and Vanderbilt Genetics Institute (T.J.H.), Vanderbilt University Medical Center, Nashville, TN; Department of Psychiatry and Neurochemistry (K.B., H.Z.), Institute of Neuroscience and Physiology, The Sahlgrenska Academy at University of Gothenburg; Clinical Neurochemistry Laboratory (K.B., H.Z.), Sahlgrenska University Hospital, Molndal, Sweden; Department of Neurodegenerative Disease (H.Z.), University College London Institute of Neurology, Queen Square; and United Kingdom Dementia Research Institute at University College London (H.Z.), UK
| | - Judy Li
- From the Vanderbilt Memory & Alzheimer's Center (E.E.M., D.L., J.L., S.J.S., F.E.C., K.R.P., M.E.M., K.A.G., T.J.H., A.L.J.), Department of Biostatistics (D.L.), Radiology & Radiological Sciences (J.G.T., S.N., J.J.C.), Department of Neurology (K.R.P., M.E.M., K.A.G., T.J.H., A.L.J.), Division of Cardiovascular Medicine (S.P.B., J.A.B., A.L.J.), Department of Medicine, and Vanderbilt Genetics Institute (T.J.H.), Vanderbilt University Medical Center, Nashville, TN; Department of Psychiatry and Neurochemistry (K.B., H.Z.), Institute of Neuroscience and Physiology, The Sahlgrenska Academy at University of Gothenburg; Clinical Neurochemistry Laboratory (K.B., H.Z.), Sahlgrenska University Hospital, Molndal, Sweden; Department of Neurodegenerative Disease (H.Z.), University College London Institute of Neurology, Queen Square; and United Kingdom Dementia Research Institute at University College London (H.Z.), UK
| | - Samantha J Schimmel
- From the Vanderbilt Memory & Alzheimer's Center (E.E.M., D.L., J.L., S.J.S., F.E.C., K.R.P., M.E.M., K.A.G., T.J.H., A.L.J.), Department of Biostatistics (D.L.), Radiology & Radiological Sciences (J.G.T., S.N., J.J.C.), Department of Neurology (K.R.P., M.E.M., K.A.G., T.J.H., A.L.J.), Division of Cardiovascular Medicine (S.P.B., J.A.B., A.L.J.), Department of Medicine, and Vanderbilt Genetics Institute (T.J.H.), Vanderbilt University Medical Center, Nashville, TN; Department of Psychiatry and Neurochemistry (K.B., H.Z.), Institute of Neuroscience and Physiology, The Sahlgrenska Academy at University of Gothenburg; Clinical Neurochemistry Laboratory (K.B., H.Z.), Sahlgrenska University Hospital, Molndal, Sweden; Department of Neurodegenerative Disease (H.Z.), University College London Institute of Neurology, Queen Square; and United Kingdom Dementia Research Institute at University College London (H.Z.), UK
| | - Francis E Cambronero
- From the Vanderbilt Memory & Alzheimer's Center (E.E.M., D.L., J.L., S.J.S., F.E.C., K.R.P., M.E.M., K.A.G., T.J.H., A.L.J.), Department of Biostatistics (D.L.), Radiology & Radiological Sciences (J.G.T., S.N., J.J.C.), Department of Neurology (K.R.P., M.E.M., K.A.G., T.J.H., A.L.J.), Division of Cardiovascular Medicine (S.P.B., J.A.B., A.L.J.), Department of Medicine, and Vanderbilt Genetics Institute (T.J.H.), Vanderbilt University Medical Center, Nashville, TN; Department of Psychiatry and Neurochemistry (K.B., H.Z.), Institute of Neuroscience and Physiology, The Sahlgrenska Academy at University of Gothenburg; Clinical Neurochemistry Laboratory (K.B., H.Z.), Sahlgrenska University Hospital, Molndal, Sweden; Department of Neurodegenerative Disease (H.Z.), University College London Institute of Neurology, Queen Square; and United Kingdom Dementia Research Institute at University College London (H.Z.), UK
| | - James G Terry
- From the Vanderbilt Memory & Alzheimer's Center (E.E.M., D.L., J.L., S.J.S., F.E.C., K.R.P., M.E.M., K.A.G., T.J.H., A.L.J.), Department of Biostatistics (D.L.), Radiology & Radiological Sciences (J.G.T., S.N., J.J.C.), Department of Neurology (K.R.P., M.E.M., K.A.G., T.J.H., A.L.J.), Division of Cardiovascular Medicine (S.P.B., J.A.B., A.L.J.), Department of Medicine, and Vanderbilt Genetics Institute (T.J.H.), Vanderbilt University Medical Center, Nashville, TN; Department of Psychiatry and Neurochemistry (K.B., H.Z.), Institute of Neuroscience and Physiology, The Sahlgrenska Academy at University of Gothenburg; Clinical Neurochemistry Laboratory (K.B., H.Z.), Sahlgrenska University Hospital, Molndal, Sweden; Department of Neurodegenerative Disease (H.Z.), University College London Institute of Neurology, Queen Square; and United Kingdom Dementia Research Institute at University College London (H.Z.), UK
| | - Sangeeta Nair
- From the Vanderbilt Memory & Alzheimer's Center (E.E.M., D.L., J.L., S.J.S., F.E.C., K.R.P., M.E.M., K.A.G., T.J.H., A.L.J.), Department of Biostatistics (D.L.), Radiology & Radiological Sciences (J.G.T., S.N., J.J.C.), Department of Neurology (K.R.P., M.E.M., K.A.G., T.J.H., A.L.J.), Division of Cardiovascular Medicine (S.P.B., J.A.B., A.L.J.), Department of Medicine, and Vanderbilt Genetics Institute (T.J.H.), Vanderbilt University Medical Center, Nashville, TN; Department of Psychiatry and Neurochemistry (K.B., H.Z.), Institute of Neuroscience and Physiology, The Sahlgrenska Academy at University of Gothenburg; Clinical Neurochemistry Laboratory (K.B., H.Z.), Sahlgrenska University Hospital, Molndal, Sweden; Department of Neurodegenerative Disease (H.Z.), University College London Institute of Neurology, Queen Square; and United Kingdom Dementia Research Institute at University College London (H.Z.), UK
| | - Kimberly R Pechman
- From the Vanderbilt Memory & Alzheimer's Center (E.E.M., D.L., J.L., S.J.S., F.E.C., K.R.P., M.E.M., K.A.G., T.J.H., A.L.J.), Department of Biostatistics (D.L.), Radiology & Radiological Sciences (J.G.T., S.N., J.J.C.), Department of Neurology (K.R.P., M.E.M., K.A.G., T.J.H., A.L.J.), Division of Cardiovascular Medicine (S.P.B., J.A.B., A.L.J.), Department of Medicine, and Vanderbilt Genetics Institute (T.J.H.), Vanderbilt University Medical Center, Nashville, TN; Department of Psychiatry and Neurochemistry (K.B., H.Z.), Institute of Neuroscience and Physiology, The Sahlgrenska Academy at University of Gothenburg; Clinical Neurochemistry Laboratory (K.B., H.Z.), Sahlgrenska University Hospital, Molndal, Sweden; Department of Neurodegenerative Disease (H.Z.), University College London Institute of Neurology, Queen Square; and United Kingdom Dementia Research Institute at University College London (H.Z.), UK
| | - Marissa E Moore
- From the Vanderbilt Memory & Alzheimer's Center (E.E.M., D.L., J.L., S.J.S., F.E.C., K.R.P., M.E.M., K.A.G., T.J.H., A.L.J.), Department of Biostatistics (D.L.), Radiology & Radiological Sciences (J.G.T., S.N., J.J.C.), Department of Neurology (K.R.P., M.E.M., K.A.G., T.J.H., A.L.J.), Division of Cardiovascular Medicine (S.P.B., J.A.B., A.L.J.), Department of Medicine, and Vanderbilt Genetics Institute (T.J.H.), Vanderbilt University Medical Center, Nashville, TN; Department of Psychiatry and Neurochemistry (K.B., H.Z.), Institute of Neuroscience and Physiology, The Sahlgrenska Academy at University of Gothenburg; Clinical Neurochemistry Laboratory (K.B., H.Z.), Sahlgrenska University Hospital, Molndal, Sweden; Department of Neurodegenerative Disease (H.Z.), University College London Institute of Neurology, Queen Square; and United Kingdom Dementia Research Institute at University College London (H.Z.), UK
| | - Susan P Bell
- From the Vanderbilt Memory & Alzheimer's Center (E.E.M., D.L., J.L., S.J.S., F.E.C., K.R.P., M.E.M., K.A.G., T.J.H., A.L.J.), Department of Biostatistics (D.L.), Radiology & Radiological Sciences (J.G.T., S.N., J.J.C.), Department of Neurology (K.R.P., M.E.M., K.A.G., T.J.H., A.L.J.), Division of Cardiovascular Medicine (S.P.B., J.A.B., A.L.J.), Department of Medicine, and Vanderbilt Genetics Institute (T.J.H.), Vanderbilt University Medical Center, Nashville, TN; Department of Psychiatry and Neurochemistry (K.B., H.Z.), Institute of Neuroscience and Physiology, The Sahlgrenska Academy at University of Gothenburg; Clinical Neurochemistry Laboratory (K.B., H.Z.), Sahlgrenska University Hospital, Molndal, Sweden; Department of Neurodegenerative Disease (H.Z.), University College London Institute of Neurology, Queen Square; and United Kingdom Dementia Research Institute at University College London (H.Z.), UK
| | - Joshua A Beckman
- From the Vanderbilt Memory & Alzheimer's Center (E.E.M., D.L., J.L., S.J.S., F.E.C., K.R.P., M.E.M., K.A.G., T.J.H., A.L.J.), Department of Biostatistics (D.L.), Radiology & Radiological Sciences (J.G.T., S.N., J.J.C.), Department of Neurology (K.R.P., M.E.M., K.A.G., T.J.H., A.L.J.), Division of Cardiovascular Medicine (S.P.B., J.A.B., A.L.J.), Department of Medicine, and Vanderbilt Genetics Institute (T.J.H.), Vanderbilt University Medical Center, Nashville, TN; Department of Psychiatry and Neurochemistry (K.B., H.Z.), Institute of Neuroscience and Physiology, The Sahlgrenska Academy at University of Gothenburg; Clinical Neurochemistry Laboratory (K.B., H.Z.), Sahlgrenska University Hospital, Molndal, Sweden; Department of Neurodegenerative Disease (H.Z.), University College London Institute of Neurology, Queen Square; and United Kingdom Dementia Research Institute at University College London (H.Z.), UK
| | - Katherine A Gifford
- From the Vanderbilt Memory & Alzheimer's Center (E.E.M., D.L., J.L., S.J.S., F.E.C., K.R.P., M.E.M., K.A.G., T.J.H., A.L.J.), Department of Biostatistics (D.L.), Radiology & Radiological Sciences (J.G.T., S.N., J.J.C.), Department of Neurology (K.R.P., M.E.M., K.A.G., T.J.H., A.L.J.), Division of Cardiovascular Medicine (S.P.B., J.A.B., A.L.J.), Department of Medicine, and Vanderbilt Genetics Institute (T.J.H.), Vanderbilt University Medical Center, Nashville, TN; Department of Psychiatry and Neurochemistry (K.B., H.Z.), Institute of Neuroscience and Physiology, The Sahlgrenska Academy at University of Gothenburg; Clinical Neurochemistry Laboratory (K.B., H.Z.), Sahlgrenska University Hospital, Molndal, Sweden; Department of Neurodegenerative Disease (H.Z.), University College London Institute of Neurology, Queen Square; and United Kingdom Dementia Research Institute at University College London (H.Z.), UK
| | - Timothy J Hohman
- From the Vanderbilt Memory & Alzheimer's Center (E.E.M., D.L., J.L., S.J.S., F.E.C., K.R.P., M.E.M., K.A.G., T.J.H., A.L.J.), Department of Biostatistics (D.L.), Radiology & Radiological Sciences (J.G.T., S.N., J.J.C.), Department of Neurology (K.R.P., M.E.M., K.A.G., T.J.H., A.L.J.), Division of Cardiovascular Medicine (S.P.B., J.A.B., A.L.J.), Department of Medicine, and Vanderbilt Genetics Institute (T.J.H.), Vanderbilt University Medical Center, Nashville, TN; Department of Psychiatry and Neurochemistry (K.B., H.Z.), Institute of Neuroscience and Physiology, The Sahlgrenska Academy at University of Gothenburg; Clinical Neurochemistry Laboratory (K.B., H.Z.), Sahlgrenska University Hospital, Molndal, Sweden; Department of Neurodegenerative Disease (H.Z.), University College London Institute of Neurology, Queen Square; and United Kingdom Dementia Research Institute at University College London (H.Z.), UK
| | - Kaj Blennow
- From the Vanderbilt Memory & Alzheimer's Center (E.E.M., D.L., J.L., S.J.S., F.E.C., K.R.P., M.E.M., K.A.G., T.J.H., A.L.J.), Department of Biostatistics (D.L.), Radiology & Radiological Sciences (J.G.T., S.N., J.J.C.), Department of Neurology (K.R.P., M.E.M., K.A.G., T.J.H., A.L.J.), Division of Cardiovascular Medicine (S.P.B., J.A.B., A.L.J.), Department of Medicine, and Vanderbilt Genetics Institute (T.J.H.), Vanderbilt University Medical Center, Nashville, TN; Department of Psychiatry and Neurochemistry (K.B., H.Z.), Institute of Neuroscience and Physiology, The Sahlgrenska Academy at University of Gothenburg; Clinical Neurochemistry Laboratory (K.B., H.Z.), Sahlgrenska University Hospital, Molndal, Sweden; Department of Neurodegenerative Disease (H.Z.), University College London Institute of Neurology, Queen Square; and United Kingdom Dementia Research Institute at University College London (H.Z.), UK
| | - Henrik Zetterberg
- From the Vanderbilt Memory & Alzheimer's Center (E.E.M., D.L., J.L., S.J.S., F.E.C., K.R.P., M.E.M., K.A.G., T.J.H., A.L.J.), Department of Biostatistics (D.L.), Radiology & Radiological Sciences (J.G.T., S.N., J.J.C.), Department of Neurology (K.R.P., M.E.M., K.A.G., T.J.H., A.L.J.), Division of Cardiovascular Medicine (S.P.B., J.A.B., A.L.J.), Department of Medicine, and Vanderbilt Genetics Institute (T.J.H.), Vanderbilt University Medical Center, Nashville, TN; Department of Psychiatry and Neurochemistry (K.B., H.Z.), Institute of Neuroscience and Physiology, The Sahlgrenska Academy at University of Gothenburg; Clinical Neurochemistry Laboratory (K.B., H.Z.), Sahlgrenska University Hospital, Molndal, Sweden; Department of Neurodegenerative Disease (H.Z.), University College London Institute of Neurology, Queen Square; and United Kingdom Dementia Research Institute at University College London (H.Z.), UK
| | - John Jeffrey Carr
- From the Vanderbilt Memory & Alzheimer's Center (E.E.M., D.L., J.L., S.J.S., F.E.C., K.R.P., M.E.M., K.A.G., T.J.H., A.L.J.), Department of Biostatistics (D.L.), Radiology & Radiological Sciences (J.G.T., S.N., J.J.C.), Department of Neurology (K.R.P., M.E.M., K.A.G., T.J.H., A.L.J.), Division of Cardiovascular Medicine (S.P.B., J.A.B., A.L.J.), Department of Medicine, and Vanderbilt Genetics Institute (T.J.H.), Vanderbilt University Medical Center, Nashville, TN; Department of Psychiatry and Neurochemistry (K.B., H.Z.), Institute of Neuroscience and Physiology, The Sahlgrenska Academy at University of Gothenburg; Clinical Neurochemistry Laboratory (K.B., H.Z.), Sahlgrenska University Hospital, Molndal, Sweden; Department of Neurodegenerative Disease (H.Z.), University College London Institute of Neurology, Queen Square; and United Kingdom Dementia Research Institute at University College London (H.Z.), UK
| | - Angela L Jefferson
- From the Vanderbilt Memory & Alzheimer's Center (E.E.M., D.L., J.L., S.J.S., F.E.C., K.R.P., M.E.M., K.A.G., T.J.H., A.L.J.), Department of Biostatistics (D.L.), Radiology & Radiological Sciences (J.G.T., S.N., J.J.C.), Department of Neurology (K.R.P., M.E.M., K.A.G., T.J.H., A.L.J.), Division of Cardiovascular Medicine (S.P.B., J.A.B., A.L.J.), Department of Medicine, and Vanderbilt Genetics Institute (T.J.H.), Vanderbilt University Medical Center, Nashville, TN; Department of Psychiatry and Neurochemistry (K.B., H.Z.), Institute of Neuroscience and Physiology, The Sahlgrenska Academy at University of Gothenburg; Clinical Neurochemistry Laboratory (K.B., H.Z.), Sahlgrenska University Hospital, Molndal, Sweden; Department of Neurodegenerative Disease (H.Z.), University College London Institute of Neurology, Queen Square; and United Kingdom Dementia Research Institute at University College London (H.Z.), UK.
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9
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Kresge HA, Liu D, Gupta DK, Moore EE, Osborn KE, Acosta LMY, Bell SP, Pechman KR, Gifford KA, Mendes LA, Wang TJ, Blennow K, Zetterberg H, Hohman TJ, Jefferson AL. Lower Left Ventricular Ejection Fraction Relates to Cerebrospinal Fluid Biomarker Evidence of Neurodegeneration in Older Adults. J Alzheimers Dis 2021; 74:965-974. [PMID: 32144980 DOI: 10.3233/jad-190813] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Subclinical cardiac dysfunction is associated with decreased cerebral blood flow, placing the aging brain at risk for Alzheimer's disease (AD) pathology and neurodegeneration. OBJECTIVE This study investigates the association between subclinical cardiac dysfunction, measured by left ventricular ejection fraction (LVEF), and cerebrospinal fluid (CSF) biomarkers of AD and neurodegeneration. METHODS Vanderbilt Memory & Aging Project participants free of dementia, stroke, and heart failure (n = 152, 72±6 years, 68% male) underwent echocardiogram to quantify LVEF and lumbar puncture to measure CSF levels of amyloid-β42 (Aβ42), phosphorylated tau (p-tau), and total tau (t-tau). Linear regressions related LVEF to CSF biomarkers, adjusting for age, sex, race/ethnicity, education, Framingham Stroke Risk Profile, cognitive diagnosis, and apolipoprotein E ɛ4 status. Secondary models tested an LVEF x cognitive diagnosis interaction and then stratified by diagnosis (normal cognition (NC), mild cognitive impairment (MCI)). RESULTS Higher LVEF related to decreased CSF Aβ42 levels (β= -6.50, p = 0.04) reflecting greater cerebral amyloid accumulation, but this counterintuitive result was attenuated after excluding participants with cardiovascular disease and atrial fibrillation (p = 0.07). We observed an interaction between LVEF and cognitive diagnosis on CSF t-tau (p = 0.004) and p-tau levels (p = 0.002), whereas lower LVEF was associated with increased CSF t-tau (β= -9.74, p = 0.01) and p-tau in the NC (β= -1.41, p = 0.003) but not MCI participants (p-values>0.13). CONCLUSIONS Among cognitively normal older adults, subclinically lower LVEF relates to greater molecular evidence of tau phosphorylation and neurodegeneration. Modest age-related changes in cardiovascular function may have implications for pathophysiological changes in the brain later in life.
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Affiliation(s)
- Hailey A Kresge
- Vanderbilt Memory & Alzheimer's Center, Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Dandan Liu
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Deepak K Gupta
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Elizabeth E Moore
- Vanderbilt Memory & Alzheimer's Center, Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Katie E Osborn
- Vanderbilt Memory & Alzheimer's Center, Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Lealani Mae Y Acosta
- Vanderbilt Memory & Alzheimer's Center, Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Susan P Bell
- Vanderbilt Memory & Alzheimer's Center, Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA.,Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.,Center for Quality Aging, Division of General Internal Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kimberly R Pechman
- Vanderbilt Memory & Alzheimer's Center, Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Katherine A Gifford
- Vanderbilt Memory & Alzheimer's Center, Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Lisa A Mendes
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Thomas J Wang
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kaj Blennow
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at University of Gothenburg, Mölndal, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at University of Gothenburg, Mölndal, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden.,Department of Neurodegenerative Disease, UCL Institute of Neurology, Queen Square, London, UK.,UK Dementia Research Institute at UCL, London, UK
| | - Timothy J Hohman
- Vanderbilt Memory & Alzheimer's Center, Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA.,Vanderbilt Genetics Institute, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Angela L Jefferson
- Vanderbilt Memory & Alzheimer's Center, Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA.,Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
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10
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Lawson MA, Hansen DE, Gupta DK, Bell SP, Adkisson DW, Mallugari RR, Sawyer DB, Ooi H, Kronenberg MW. Modification of ventriculo-arterial coupling by spironolactone in nonischemic dilated cardiomyopathy. ESC Heart Fail 2021; 8:1156-1166. [PMID: 33403831 PMCID: PMC8006677 DOI: 10.1002/ehf2.13161] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 10/23/2020] [Accepted: 11/20/2020] [Indexed: 01/19/2023] Open
Abstract
Aims We sought to clarify the role of ventriculo–arterial (V–A) coupling in the treatment of nonischemic dilated cardiomyopathy (NIDCM) by adding a mineralocorticoid receptor antagonist (MRA) to conventional anti‐failure therapy. Methods and results We employed cardiac magnetic resonance imaging to quantify left ventricular (LV) contractility and V–A coupling in normal subjects at rest (n = 11) and in patients with NIDCM (n = 12) before and after long term anti‐failure therapy, in which MRA was added to conventional anti‐failure therapy. After ≥6 months' treatment in NIDCM patients, LV volumes and mass decreased, and the LV ejection fraction increased from a median of 24% (17, 27) (interquartile range IQR) to 47 (42, 52) (P < 0.002), with a marked reduction in arterial elastance (Ea) from 2.89 mmHg/mL (2.34, 4.0) to 1.50 (1.29, 1.95) (P < 0.002), similar to Ea of normal subjects, 1.53 (1.34, 1.67) (P > 0.05). The V–A coupling ratio, Ea/end‐systolic elastance (single‐beat method), decreased by −1.08 (−1.96, −0.55), (P = 0.003), as did Ea/end‐systolic pressure/end‐systolic pressure ratio, −0.54 (0.35, 0.87), (P = 0.002). The preload recruitable stroke work (PRSW) increased as did PRSW indexed for Ea (both P = 0.002), which reflected ‘total circulatory performance’. Conclusions In NIDCM, adding MRA to conventional anti‐failure therapy markedly improved LV ejection fraction and reduced peripheral vascular resistance, due to both improved LV contractility and especially to enhanced V–A coupling, as Ea decreased to normal. Total circulatory performance was a sensitive indicator of both LV pump performance and the arterial loading conditions.
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Affiliation(s)
- Mark A Lawson
- VA Tennessee Valley Health Care System, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
| | - David E Hansen
- VA Tennessee Valley Health Care System, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
| | - Deepak K Gupta
- VA Tennessee Valley Health Care System, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
| | - Susan P Bell
- VA Tennessee Valley Health Care System, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
| | - Douglas W Adkisson
- VA Tennessee Valley Health Care System, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
| | - Ravinder R Mallugari
- VA Tennessee Valley Health Care System, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
| | - Douglas B Sawyer
- VA Tennessee Valley Health Care System, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
| | - Henry Ooi
- VA Tennessee Valley Health Care System, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
| | - Marvin W Kronenberg
- VA Tennessee Valley Health Care System, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
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11
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Meier SE, Khan OA, Liu D, Bown CW, Moore EE, Pechman KR, Acosta LMY, Bell SP, Blennow K, Zetterberg H, Gifford KA, Hohman TJ, Jefferson AL. Cerebrospinal fluid phosphorylated tau interacts with MMP2 and MMP3: Associations with cognitive performance in older adults. Alzheimers Dement 2020. [DOI: 10.1002/alz.046463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
| | - Omair A. Khan
- Vanderbilt University Medical Center Nashville TN USA
| | - Dandan Liu
- Vanderbilt University Medical Center Nashville TN USA
| | - Corey W. Bown
- Vanderbilt University Medical Center Nashville TN USA
| | | | | | | | - Susan P. Bell
- Vanderbilt University Medical Center Nashville TN USA
| | - Kaj Blennow
- Institute of Neuroscience and Physiology University of Gothenburg Mölndal Sweden
| | - Henrik Zetterberg
- Institute of Neuroscience and Physiology Department of Psychiatry and Neurochemistry The Sahlgrenska Academy at University of Gothenburg Mölndal Sweden
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12
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Moore EE, Khan OA, Liu D, Pechman KR, Acosta LMY, Bell SP, Landman BA, Blennow K, Zetterberg H, Hohman TJ, Gifford KA, Jefferson AL. Baseline cerebrospinal fluid biomarkers of amyloidosis, phosphorylated tau, and total tau relate to greater longitudinal atrophy in regions susceptible to Alzheimer’s disease‐related neurodegeneration. Alzheimers Dement 2020. [DOI: 10.1002/alz.046095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
| | - Omair A. Khan
- Vanderbilt University Medical Center Nashville TN USA
| | - Dandan Liu
- Vanderbilt University Medical Center Nashville TN USA
| | | | | | - Susan P. Bell
- Vanderbilt University Medical Center Nashville TN USA
| | | | - Kaj Blennow
- Institute of Neuroscience and Physiology University of Gothenburg Mölndal Sweden
| | - Henrik Zetterberg
- Institute of Neuroscience and Physiology Department of Psychiatry and Neurochemistry The Sahlgrenska Academy at University of Gothenburg Mölndal Sweden
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13
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Moore EE, Liu D, Pechman KR, Acosta LMY, Bell SP, Davis LT, Blennow K, Zetterberg H, Landman BA, Schrag MS, Hohman TJ, Gifford KA, Jefferson AL. Mild Cognitive Impairment Staging Yields Genetic Susceptibility, Biomarker, and Neuroimaging Differences. Front Aging Neurosci 2020; 12:139. [PMID: 32581762 PMCID: PMC7289958 DOI: 10.3389/fnagi.2020.00139] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 04/27/2020] [Indexed: 01/22/2023] Open
Abstract
Introduction While Alzheimer’s disease (AD) is divided into severity stages, mild cognitive impairment (MCI) remains a solitary construct despite clinical and prognostic heterogeneity. This study aimed to characterize differences in genetic, cerebrospinal fluid (CSF), neuroimaging, and neuropsychological markers across clinician-derived MCI stages. Methods Vanderbilt Memory & Aging Project participants with MCI were categorized into 3 severity subtypes at screening based on neuropsychological assessment, functional assessment, and Clinical Dementia Rating interview, including mild (n = 18, 75 ± 8 years), moderate (n = 89 72 ± 7 years), and severe subtypes (n = 18, 78 ± 8 years). At enrollment, participants underwent neuropsychological testing, 3T brain magnetic resonance imaging (MRI), and optional fasting lumbar puncture to obtain CSF. Neuropsychological testing and MRI were repeated at 18-months, 3-years, and 5-years with a mean follow-up time of 3.3 years. Ordinary least square regressions examined cross-sectional associations between MCI severity and apolipoprotein E (APOE)-ε4 status, CSF biomarkers of amyloid beta (Aβ), phosphorylated tau, total tau, and synaptic dysfunction (neurogranin), baseline neuroimaging biomarkers, and baseline neuropsychological performance. Longitudinal associations between baseline MCI severity and neuroimaging and neuropsychological trajectory were assessed using linear mixed effects models with random intercepts and slopes and a follow-up time interaction. Analyses adjusted for baseline age, sex, race/ethnicity, education, and intracranial volume for MRI models. Results Stages differed at baseline on APOE-ε4 status (early < middle = late; p-values < 0.03) and CSF Aβ (early > middle = late), phosphorylated and total tau (early = middle < late; p-values < 0.05), and neurogranin concentrations (early = middle < late; p-values < 0.05). MCI stage related to greater longitudinal cognitive decline, hippocampal atrophy, and inferior lateral ventricle dilation (early < late; p-values < 0.03). Discussion Clinician staging of MCI severity yielded longitudinal cognitive trajectory and structural neuroimaging differences in regions susceptible to AD neuropathology and neurodegeneration. As expected, participants with more severe MCI symptoms at study entry had greater cognitive decline and gray matter atrophy over time. Differences are likely attributable to baseline differences in amyloidosis, tau, and synaptic dysfunction. MCI staging may provide insight into underlying pathology, prognosis, and therapeutic targets.
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Affiliation(s)
- Elizabeth E Moore
- Vanderbilt Memory & Alzheimer's Center, Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Dandan Liu
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Kimberly R Pechman
- Vanderbilt Memory & Alzheimer's Center, Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Lealani Mae Y Acosta
- Vanderbilt Memory & Alzheimer's Center, Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Susan P Bell
- Vanderbilt Memory & Alzheimer's Center, Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, United States.,Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - L Taylor Davis
- Vanderbilt Memory & Alzheimer's Center, Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, United States.,Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Kaj Blennow
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at University of Gothenburg, Mölndal, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at University of Gothenburg, Mölndal, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden.,Department of Neurodegenerative Disease, UCL Institute of Neurology, London, United Kingdom.,UK Dementia Research Institute at UCL, London, United Kingdom
| | - Bennett A Landman
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, United States.,Department of Biomedical Engineering, Vanderbilt University, Nashville, TN, United States.,Department of Electrical Engineering and Computer Science, Vanderbilt University, Nashville, TN, United States
| | - Matthew S Schrag
- Vanderbilt Memory & Alzheimer's Center, Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Timothy J Hohman
- Vanderbilt Memory & Alzheimer's Center, Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, United States.,Vanderbilt Genetics Institute, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Katherine A Gifford
- Vanderbilt Memory & Alzheimer's Center, Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Angela L Jefferson
- Vanderbilt Memory & Alzheimer's Center, Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, United States.,Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
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14
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Moore EE, Gifford KA, Khan OA, Liu D, Pechman KR, Acosta LMY, Bell SP, Turchan M, Landman BA, Blennow K, Zetterberg H, Hohman TJ, Jefferson AL. Cerebrospinal fluid biomarkers of neurodegeneration, synaptic dysfunction, and axonal injury relate to atrophy in structural brain regions specific to Alzheimer's disease. Alzheimers Dement 2020; 16:883-895. [PMID: 32378327 DOI: 10.1002/alz.12087] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 01/09/2020] [Accepted: 01/15/2020] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Patterns of atrophy can distinguish normal cognition from Alzheimer's disease (AD), but neuropathological drivers of this pattern are unknown. This study examined associations between cerebrospinal fluid biomarkers of AD pathology, synaptic dysfunction, and neuroaxonal injury with two AD imaging signatures. METHODS Signatures were calculated using published guidelines. Linear regressions related each biomarker to both signatures, adjusting for demographic factors. Bootstrapped analyses tested if associations were stronger with one signature versus the other. RESULTS Increased phosphorylated tau (p-tau), total tau, and neurofilament light (P-values <.045) related to smaller signatures (indicating greater atrophy). Diagnosis and sex modified associations between p-tau and neurogranin (P-values<.05) and signatures, such that associations were stronger among participants with mild cognitive impairment and female participants. The strength of associations did not differ between signatures. DISCUSSION Increased evidence of neurodegeneration, axonopathy, and tau phosphorylation relate to greater AD-related atrophy. Tau phosphorylation and synaptic dysfunction may be more prominent in AD-affected regions in females.
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Affiliation(s)
- Elizabeth E Moore
- Department of Neurology, Vanderbilt Memory & Alzheimer's Center, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Katherine A Gifford
- Department of Neurology, Vanderbilt Memory & Alzheimer's Center, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Omair A Khan
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Dandan Liu
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kimberly R Pechman
- Department of Neurology, Vanderbilt Memory & Alzheimer's Center, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Lealani Mae Y Acosta
- Department of Neurology, Vanderbilt Memory & Alzheimer's Center, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Susan P Bell
- Department of Neurology, Vanderbilt Memory & Alzheimer's Center, Vanderbilt University Medical Center, Nashville, Tennessee.,Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Maxim Turchan
- Department of Neurology, Vanderbilt Memory & Alzheimer's Center, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Bennett A Landman
- Department of Radiology & Radiological Sciences, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Biomedical Engineering, Vanderbilt University, Nashville, Tennessee.,Department of Electrical Engineering and Computer Science, Vanderbilt University, Nashville, Tennessee
| | - Kaj Blennow
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at University of Gothenburg, Mölndal, Sweden.,Clinical Neurochemistry Lab, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at University of Gothenburg, Mölndal, Sweden.,Clinical Neurochemistry Lab, Sahlgrenska University Hospital, Mölndal, Sweden.,Department of Neurodegenerative Disease, UCL Institute of Neurology, Queen Square, London, UK.,UK Dementia Research Institute at UCL, London, UK
| | - Timothy J Hohman
- Department of Neurology, Vanderbilt Memory & Alzheimer's Center, Vanderbilt University Medical Center, Nashville, Tennessee.,Vanderbilt Genetics Institute, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Angela L Jefferson
- Department of Neurology, Vanderbilt Memory & Alzheimer's Center, Vanderbilt University Medical Center, Nashville, Tennessee.,Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
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15
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Jefferson AL, Cambronero FE, Liu D, Moore EE, Neal JE, Terry JG, Nair S, Pechman KR, Rane S, Davis LT, Gifford KA, Hohman TJ, Bell SP, Wang TJ, Beckman JA, Carr JJ. Higher Aortic Stiffness Is Related to Lower Cerebral Blood Flow and Preserved Cerebrovascular Reactivity in Older Adults. Circulation 2019; 138:1951-1962. [PMID: 30018169 DOI: 10.1161/circulationaha.118.032410] [Citation(s) in RCA: 92] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Mechanisms underlying the association between age-related arterial stiffening and poor brain health remain elusive. Cerebral blood flow (CBF) homeostasis may be implicated. This study evaluates how aortic stiffening relates to resting CBF and cerebrovascular reactivity (CVR) in older adults. METHODS Vanderbilt Memory & Aging Project participants free of clinical dementia, stroke, and heart failure were studied, including older adults with normal cognition (n=155; age, 72±7 years; 59% male) or mild cognitive impairment (n=115; age, 73±7 years; 57% male). Aortic pulse wave velocity (PWV; meters per second) was quantified from cardiac magnetic resonance. Resting CBF (milliliters per 100 g per minute) and CVR (CBF response to hypercapnic normoxia stimulus) were quantified from pseudocontinuous arterial spin labeling magnetic resonance imaging. Linear regression models related aortic PWV to regional CBF, adjusting for age, race/ethnicity, education, Framingham Stroke Risk Profile (diabetes mellitus, smoking, left ventricular hypertrophy, prevalent cardiovascular disease, atrial fibrillation), hypertension, body mass index, apolipoprotein E4 ( APOE ε4) status, and regional tissue volume. Models were repeated testing PWV× APOE ε4 interactions. Sensitivity analyses excluded participants with prevalent cardiovascular disease and atrial fibrillation. RESULTS Among participants with normal cognition, higher aortic PWV related to lower frontal lobe CBF (β=-0.43; P=0.04) and higher CVR in the whole brain (β=0.11; P=0.02), frontal lobes (β=0.12; P<0.05), temporal lobes (β=0.11; P=0.02), and occipital lobes (β=0.14; P=0.01). Among APOE ε4 carriers with normal cognition, findings were more pronounced with higher PWV relating to lower whole-brain CBF (β=-1.16; P=0.047), lower temporal lobe CBF (β=-1.81; P=0.004), and higher temporal lobe CVR (β=0.26; P=0.08), although the last result did not meet the a priori significance threshold. Results were similar in sensitivity models. Among participants with mild cognitive impairment, higher aortic PWV related to lower CBF in the occipital lobe (β=-0.70; P=0.02), but this finding was attenuated when participants with prevalent cardiovascular disease and atrial fibrillation were excluded. Among APOE ε4 carriers with mild cognitive impairment, findings were more pronounced with higher PWV relating to lower temporal lobe CBF (β=-1.20; P=0.02). CONCLUSIONS Greater aortic stiffening relates to lower regional CBF and higher CVR in cognitively normal older adults, especially among individuals with increased genetic predisposition for Alzheimer's disease. Central arterial stiffening may contribute to reductions in regional CBF despite preserved cerebrovascular reserve capacity.
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Affiliation(s)
- Angela L Jefferson
- Vanderbilt Memory & Alzheimer's Center, Department of Neurology (A.L.J., F.E.C., E.E.M., K.R.P., K.A.G., T.J.H.), Vanderbilt University Medical Center, Nashville, TN.,Division of Cardiovascular Medicine, Department of Medicine (A.L.J., S.P.B., T.J.W., J.A.B), Vanderbilt University Medical Center, Nashville, TN
| | - Francis E Cambronero
- Vanderbilt Memory & Alzheimer's Center, Department of Neurology (A.L.J., F.E.C., E.E.M., K.R.P., K.A.G., T.J.H.), Vanderbilt University Medical Center, Nashville, TN.,Vanderbilt Brain Institute, Vanderbilt University School of Medicine, Nashville, TN (F.E.C., E.E.M.)
| | - Dandan Liu
- Department of Biostatistics (D.L., J.E.N.), Vanderbilt University Medical Center, Nashville, TN
| | - Elizabeth E Moore
- Vanderbilt Memory & Alzheimer's Center, Department of Neurology (A.L.J., F.E.C., E.E.M., K.R.P., K.A.G., T.J.H.), Vanderbilt University Medical Center, Nashville, TN.,Vanderbilt Brain Institute, Vanderbilt University School of Medicine, Nashville, TN (F.E.C., E.E.M.)
| | - Jacquelyn E Neal
- Department of Biostatistics (D.L., J.E.N.), Vanderbilt University Medical Center, Nashville, TN
| | - James G Terry
- Radiology and Radiological Sciences (J.G.T., S.N., L.T.D., J.J.C.), Vanderbilt University Medical Center, Nashville, TN
| | - Sangeeta Nair
- Radiology and Radiological Sciences (J.G.T., S.N., L.T.D., J.J.C.), Vanderbilt University Medical Center, Nashville, TN
| | - Kimberly R Pechman
- Vanderbilt Memory & Alzheimer's Center, Department of Neurology (A.L.J., F.E.C., E.E.M., K.R.P., K.A.G., T.J.H.), Vanderbilt University Medical Center, Nashville, TN
| | - Swati Rane
- Department of Radiology, University of Washington Medical Center, Seattle (S.R.)
| | - L Taylor Davis
- Radiology and Radiological Sciences (J.G.T., S.N., L.T.D., J.J.C.), Vanderbilt University Medical Center, Nashville, TN
| | - Katherine A Gifford
- Vanderbilt Memory & Alzheimer's Center, Department of Neurology (A.L.J., F.E.C., E.E.M., K.R.P., K.A.G., T.J.H.), Vanderbilt University Medical Center, Nashville, TN
| | - Timothy J Hohman
- Vanderbilt Memory & Alzheimer's Center, Department of Neurology (A.L.J., F.E.C., E.E.M., K.R.P., K.A.G., T.J.H.), Vanderbilt University Medical Center, Nashville, TN
| | - Susan P Bell
- Division of Cardiovascular Medicine, Department of Medicine (A.L.J., S.P.B., T.J.W., J.A.B), Vanderbilt University Medical Center, Nashville, TN.,Center for Quality Aging, Division of General Internal Medicine, Department of Medicine (S.P.B.), Vanderbilt University Medical Center, Nashville, TN
| | - Thomas J Wang
- Division of Cardiovascular Medicine, Department of Medicine (A.L.J., S.P.B., T.J.W., J.A.B), Vanderbilt University Medical Center, Nashville, TN
| | - Joshua A Beckman
- Division of Cardiovascular Medicine, Department of Medicine (A.L.J., S.P.B., T.J.W., J.A.B), Vanderbilt University Medical Center, Nashville, TN
| | - John Jeffrey Carr
- Radiology and Radiological Sciences (J.G.T., S.N., L.T.D., J.J.C.), Vanderbilt University Medical Center, Nashville, TN
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16
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Moore EE, Kresge HA, Khan OA, Bown CW, Liu D, Pechman KR, Acosta LMY, Bell SP, Shashikumar N, Ahmed HA, Turchan M, Landman BA, Blennow K, Zetterberg H, Hohman TJ, Jefferson AL, Gifford KA. P1‐008: SEX‐SPECIFIC ASSOCIATIONS OF CEREBROSPINAL FLUID TAU AND NEUROGRANIN CONCENTRATIONS WITH ALZHEIMER'S NEUROIMAGING SIGNATURES. Alzheimers Dement 2019. [DOI: 10.1016/j.jalz.2019.06.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
| | | | - Omair A. Khan
- Vanderbilt University Medical Center Nashville TN USA
| | | | - Dandan Liu
- Vanderbilt University Medical Center Nashville TN USA
| | | | | | - Susan P. Bell
- Vanderbilt University Medical Center Nashville TN USA
| | | | | | - Maxim Turchan
- Vanderbilt University Medical Center Nashville TN USA
| | | | - Kaj Blennow
- Institute of Neuroscience and Physiology, Department of Psychiatry and Neurochemistry, the Sahlgrenska Academy University of Gothenburg Mölndal Sweden
- Clinical Neurochemistry Laboratory Sahlgrenska University Hospital Mölndal Sweden
| | - Henrik Zetterberg
- Clinical Neurochemistry Laboratory Sahlgrenska University Hospital Mölndal Sweden
- UK Dementia Research Institute University College London London United Kingdom
- Institute of Neuroscience and Physiology, the Sahlgrenska Academy University of Gothenburg Gothenburg Sweden
- Department of Molecular Neuroscience University College London, Queen Square Institute of Neurology London United Kingdom
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17
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Osborn KE, Liu D, Bown CW, Khan OA, Moore EE, Gifford KA, Acosta LA, Bell SP, Hohman TJ, Blennow K, Zetterberg H, Jefferson AL. P1‐023: CEREBROSPINAL FLUID AND PLASMA NEUROFILAMENT LIGHT ELEVATIONS CORRESPOND TO WORSE COGNITIVE PERFORMANCE IN AGING ADULTS. Alzheimers Dement 2019. [DOI: 10.1016/j.jalz.2019.06.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
| | - Dandan Liu
- Vanderbilt University Medical Center Nashville TN USA
- Vanderbilt University School of Medicine Nashville TN USA
| | | | - Omair A. Khan
- Vanderbilt University Medical Center Nashville TN USA
| | | | | | | | - Susan P. Bell
- Vanderbilt University Medical Center Nashville TN USA
| | - Timothy J. Hohman
- Vanderbilt University Medical Center Nashville TN USA
- Vanderbilt University Nashville TN USA
| | - Kaj Blennow
- Institute of Neuroscience and Physiology, Department of Psychiatry and Neurochemistry, the Sahlgrenska Academy University of Gothenburg Mölndal Sweden
- Clinical Neurochemistry Laboratory Sahlgrenska University Hospital Mölndal Sweden
| | - Henrik Zetterberg
- Institute of Neuroscience and Physiology, Department of Psychiatry and Neurochemistry, the Sahlgrenska Academy University of Gothenburg Mölndal Sweden
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18
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Moore EE, Liu D, Pechman KR, Acosta LMY, Bell SP, Shashikumar N, Ahmed HA, Blennow K, Zetterberg H, Landman BA, Gifford KA, Hohman TJ, Jefferson AL. P3-301: MILD COGNITIVE IMPAIRMENT STAGING YIELDS BIOMARKER DIFFERENCES, LONGITUDINAL COGNITIVE DECLINE, AND GREY MATTER ATROPHY. Alzheimers Dement 2019. [DOI: 10.1016/j.jalz.2019.06.5066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
| | - Dandan Liu
- Vanderbilt University Medical Center; Nashville TN USA
| | | | | | - Susan P. Bell
- Vanderbilt University Medical Center; Nashville TN USA
| | | | | | - Kaj Blennow
- Institute of Neuroscience and Physiology, Department of Psychiatry and Neurochemistry; The Sahlgrenska Academy at University of Gothenburg; Mölndal Sweden
- Clinical Neurochemistry Laboratory; Sahlgrenska University Hospital; Mölndal Sweden
| | - Henrik Zetterberg
- Clinical Neurochemistry Laboratory; Sahlgrenska University Hospital; Mölndal Sweden
- U.K. Dementia Research Institute at UCL; London United Kingdom
- Institute of Neuroscience and Physiology; Sahlgrenska Academy at the University of Gothenburg; Gothenburg Sweden
- UCL Institute of Neurology, Department of Neurodegenerative Disease; University College London; Queen Square London United Kingdom
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Gifford KA, Bell SP, Liu D, Neal JE, Turchan M, Shah AS, Jefferson AL. Frailty Is Related to Subjective Cognitive Decline in Older Women without Dementia. J Am Geriatr Soc 2019; 67:1803-1811. [PMID: 31095735 DOI: 10.1111/jgs.15972] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 03/14/2019] [Accepted: 04/05/2019] [Indexed: 01/11/2023]
Abstract
OBJECTIVES Physical frailty (or loss of physiologic reserve) is associated with cognitive impairment and dementia. Subjective cognitive decline (SCD) may represent early pathologic changes of dementia. The association between these disease markers is unclear. DESIGN Cross-sectional analysis. SETTING Community-based participants from the Vanderbilt Memory & Aging Project. PARTICIPANTS A total of 306 older adults with normal cognition (NC; n = 174) or mild cognitive impairment (MCI; n = 132). MEASUREMENTS Frailty was measured using standard methods, and a composite frailty score was calculated. SCD was quantified using the Everyday Cognition Scale (ECog; total score and four domain scores). Objective cognition was assessed with the Montreal Cognitive Assessment (MoCA). Proportional odds models, stratified by sex, related the frailty composite to MoCA and total ECog score adjusting for age, education, body mass index, cognitive diagnosis, depressed mood, Framingham Stroke Risk Profile, apolipoprotein E (APOE ε4) carrier status, and height (for gait speed models). Secondary models related individual frailty components to SCD domains and explored associations in NC only. RESULTS In women, frailty composite was related to MoCA (odds ratio [OR] = .56; P = .04), a finding attenuated in sensitivity analysis (OR = .59; P = .08). Frailty composite related to ECog total (OR = 2.27; P = .02), planning (OR = 2.63; P = .02), and organization scores (OR = 2.39; P = .03). Increasing gait speed related to lower ECog total (OR = .06; P = .003) and memory scores (OR = .03; P < .001). Grip strength related to lower ECog planning score (OR = .91; P = .04). In men, frailty was unrelated to objective and subjective cognition (P values >.07). Findings were consistent in the NC group. CONCLUSION Frailty component and composite scores are related to SCD before the presence of overt dementia. Results suggest that this association is present before overt cognitive impairment. Results suggest a possible sex difference in the clinical manifestation of frailty, with primary associations noted in women. Further studies should investigate mechanisms linking early changes among frailty, SCD, and cognition. J Am Geriatr Soc, 1-9, 2019. J Am Geriatr Soc 67:1803-1811, 2019.
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Affiliation(s)
- Katherine A Gifford
- Vanderbilt Memory & Alzheimer's Center, Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Susan P Bell
- Vanderbilt Memory & Alzheimer's Center, Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee.,Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Dandan Liu
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jacquelyn E Neal
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Maxim Turchan
- Vanderbilt Memory & Alzheimer's Center, Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Avantika S Shah
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.,Center for Quality Aging, Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Angela L Jefferson
- Vanderbilt Memory & Alzheimer's Center, Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee.,Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
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20
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Vasilevskis EE, Shah AS, Hollingsworth EK, Shotwell MS, Mixon AS, Bell SP, Kripalani S, Schnelle JF, Simmons SF. A patient-centered deprescribing intervention for hospitalized older patients with polypharmacy: rationale and design of the Shed-MEDS randomized controlled trial. BMC Health Serv Res 2019; 19:165. [PMID: 30871561 PMCID: PMC6416929 DOI: 10.1186/s12913-019-3995-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Accepted: 03/06/2019] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Polypharmacy is prevalent among hospitalized older adults, particularly those being discharged to a post-care care facility (PAC). The aim of this randomized controlled trial is to determine if a patient-centered deprescribing intervention initiated in the hospital and continued in the PAC setting reduces the total number of medications among older patients. METHODS The Shed-MEDS study is a 5-year, randomized controlled clinical intervention trial comparing a patient-centered describing intervention with usual care among older (≥50 years) hospitalized patients discharged to PAC, either a skilled nursing facility (SNF) or an inpatient rehabilitation facility (IPR). Patient measurements occur at hospital enrollment, hospital discharge, within 7 days of PAC discharge, and at 60 and 90 days following PAC discharge. Patients are randomized in a permuted block fashion, with block sizes of two to four. The overall effectiveness of the intervention will be evaluated using total medication count as the primary outcome measure. We estimate that 576 patients will enroll in the study. Following attrition due to death or loss to follow-up, 420 patients will contribute measurements at 90 days, which provides 90% power to detect a 30% versus 25% reduction in total medications with an alpha error of 0.05. Secondary outcomes include the number of medications associated with geriatric syndromes, drug burden index, medication adherence, the prevalence and severity of geriatric syndromes and functional health status. DISCUSSION The Shed-MEDS trial aims to test the hypothesis that a patient-centered deprescribing intervention initiated in the hospital and continuing through the PAC stay will reduce the total number of medications 90 days following PAC discharge and result in improvements in geriatric syndromes and functional health status. The results of this trial will quantify the health outcomes associated with reducing medications for hospitalized older adults with polypharmacy who are discharged to post-acute care facilities. TRIAL REGISTRATION This trial was prospectively registered at clinicaltrials.gov ( NCT02979353 ). The trial was first registered on 12/1/2016, with an update on 09/28/17 and 10/12/2018.
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Affiliation(s)
- Eduard E. Vasilevskis
- Vanderbilt University Medical Center, Center for Quality Aging, Nashville, TN USA
- VA Tennessee Valley Healthcare System, Geriatric Research Education and Clinical Center, Nashville, TN USA
- Vanderbilt University Medical Center, Section of Hospital Medicine, Nashville, TN USA
- Vanderbilt University Medical Center, Center for Clinical Quality and Implementation Research, Nashville, TN USA
| | - Avantika S. Shah
- Vanderbilt University Medical Center, Center for Quality Aging, Nashville, TN USA
| | | | | | - Amanda S. Mixon
- Vanderbilt University Medical Center, Center for Quality Aging, Nashville, TN USA
- VA Tennessee Valley Healthcare System, Geriatric Research Education and Clinical Center, Nashville, TN USA
- Vanderbilt University Medical Center, Section of Hospital Medicine, Nashville, TN USA
- Vanderbilt University Medical Center, Center for Clinical Quality and Implementation Research, Nashville, TN USA
| | - Susan P. Bell
- Vanderbilt University Medical Center, Center for Quality Aging, Nashville, TN USA
- Division of Geriatrics, Vanderbilt University Medical Center, Nashville, TN USA
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN USA
| | - Sunil Kripalani
- Vanderbilt University Medical Center, Section of Hospital Medicine, Nashville, TN USA
- Vanderbilt University Medical Center, Center for Clinical Quality and Implementation Research, Nashville, TN USA
| | - John F. Schnelle
- Vanderbilt University Medical Center, Center for Quality Aging, Nashville, TN USA
- Division of Geriatrics, Vanderbilt University Medical Center, Nashville, TN USA
- VA Tennessee Valley Healthcare System, Geriatric Research Education and Clinical Center, Nashville, TN USA
- Vanderbilt University Medical Center, Center for Clinical Quality and Implementation Research, Nashville, TN USA
| | - Sandra F. Simmons
- Vanderbilt University Medical Center, Center for Quality Aging, Nashville, TN USA
- Division of Geriatrics, Vanderbilt University Medical Center, Nashville, TN USA
- VA Tennessee Valley Healthcare System, Geriatric Research Education and Clinical Center, Nashville, TN USA
- Vanderbilt University Medical Center, Center for Clinical Quality and Implementation Research, Nashville, TN USA
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21
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Wang J, Dietrich MS, Bell SP, Maxwell CA, Simmons SF, Kripalani S. Changes in vulnerability among older patients with cardiovascular disease in the first 90 days after hospital discharge: A secondary analysis of a cohort study. BMJ Open 2019; 9:e024766. [PMID: 30700484 PMCID: PMC6352778 DOI: 10.1136/bmjopen-2018-024766] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVES (1) To compare changes in vulnerability after hospital discharge among older patients with cardiovascular disease who were discharged home with self-care versus a home healthcare (HHC) referral and (2) to examine factors associated with changes in vulnerability in this period. DESIGN Secondary analysis of longitudinal data from a cohort study. PARTICIPANTS AND SETTING 834 older (≥65 years) patients hospitalised for acute coronary syndromes and/or acute decompensated heart failure who were discharged home with self-care (n=713) or an HHC referral (n=121). OUTCOME Vulnerability was measured using Vulnerable Elders Survey 13 (VES-13) at baseline (prior to hospital admission) and 30 days and/or 90 days after hospital discharge. Effects of HHC referral on postdischarge change in vulnerability were examined using three linear regression approaches, with potential confounding on HHC referral adjusted by propensity score matching. RESULTS Overall, 44.4% of the participants were vulnerable at prehospitalisation baseline and 34.4% were vulnerable at 90 days after hospital discharge. Compared with self-care patients, HHC-referred patients were more vulnerable at baseline (66.9% vs 40.3%), had more increase (worsening) in VES-13 score change (B=-1.34(-2.07, -0.61), p<0.001) in the initial 30 days and more decrease (improvement) in VES-13 score change (B=0.83(0.20, 1.45), p=0.01) from 30 to 90 days after hospital discharge. Baseline vulnerability and the HHC referral attributed to 14%-16% of the variance in vulnerability change during the 90 postdischarge days, and 6% was attributed by patient age, race (African-American), depressive symptoms, and outpatient visits and hospitalisations in the past year. CONCLUSION After adjusting for preceding vulnerability and covariates, older hospitalised patients with cardiovascular disease referred to HHC had delayed recovery in vulnerability in first initial 30 days after hospital discharge and greater improvement in vulnerability from 30 to 90 days after hospital discharge. HHC seemed to facilitate improvement in vulnerability among older patients with cardiovascular disease from 30 to 90 days after hospital discharge.
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Affiliation(s)
- Jinjiao Wang
- University of Rochester Medical Center, School of Nursing, Rochester, New York, USA
| | - Mary S Dietrich
- School of Nursing, Vanderbilt University, Nashville, Tennessee, USA
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Psychiatry, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Susan P Bell
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Cathy A Maxwell
- School of Nursing, Vanderbilt University, Nashville, Tennessee, USA
| | - Sandra F Simmons
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville, Tennessee, USA
| | - Sunil Kripalani
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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22
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Gifford KA, Liu D, Neal JE, Babicz MA, Thompson JL, Walljasper LE, Wiggins ME, Turchan M, Pechman KR, Osborn KE, Acosta LMY, Bell SP, Hohman TJ, Libon DJ, Blennow K, Zetterberg H, Jefferson AL. The 12-Word Philadelphia Verbal Learning Test Performances in Older Adults: Brain MRI and Cerebrospinal Fluid Correlates and Regression-Based Normative Data. Dement Geriatr Cogn Dis Extra 2018; 8:476-491. [PMID: 30631339 PMCID: PMC6323369 DOI: 10.1159/000494209] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 10/01/2018] [Indexed: 11/19/2022] Open
Abstract
Background/Aims This study evaluated neuroimaging and biological correlates, psychometric properties, and regression-based normative data of the 12-word Philadelphia Verbal Learning Test (PVLT), a list-learning test. Methods Vanderbilt Memory and Aging Project participants free of clinical dementia and stroke (n = 230, aged 73 ± 7 years) completed a neuropsychological protocol and brain MRI. A subset (n = 111) underwent lumbar puncture for analysis of Alzheimer's disease (AD) and axonal integrity cerebrospinal fluid (CSF) biomarkers. Regression models related PVLT indices to MRI and CSF biomarkers adjusting for age, sex, race/ethnicity, education, APOE-ε4 carrier status, cognitive status, and intracranial volume (MRI models). Secondary analyses were restricted to participants with normal cognition (NC; n = 127), from which regression-based normative data were generated. Results Lower PVLT performances were associated with smaller medial temporal lobe volumes (p < 0.05) and higher CSF tau concentrations (p < 0.04). Among NC, PVLT indices were associated with white matter hyperintensities on MRI and an axonal injury biomarker (CSF neurofilament light; p < 0.03). Conclusion The PVLT appears sensitive to markers of neurodegeneration, including temporal regions affected by AD. Conversely, in cognitively normal older adults, PVLT performance seems to relate to white matter disease and axonal injury, perhaps reflecting non-AD pathways to cognitive change. Enhanced normative data enrich the clinical utility of this tool.
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Affiliation(s)
- Katherine A Gifford
- Vanderbilt Memory and Alzheimer's Center, Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Dandan Liu
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jacquelyn E Neal
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Michelle A Babicz
- Vanderbilt Memory and Alzheimer's Center, Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Psychology, University of Houston, Houston, Texas, USA
| | - Jennifer L Thompson
- Vanderbilt Memory and Alzheimer's Center, Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Lily E Walljasper
- Vanderbilt Memory and Alzheimer's Center, Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Margaret E Wiggins
- Department of Clinical and Health Psychology, University of Florida, Gainesville, Florida, USA
| | - Maxim Turchan
- Vanderbilt Memory and Alzheimer's Center, Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kimberly R Pechman
- Vanderbilt Memory and Alzheimer's Center, Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Katie E Osborn
- Vanderbilt Memory and Alzheimer's Center, Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Lealani Mae Y Acosta
- Vanderbilt Memory and Alzheimer's Center, Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Susan P Bell
- Vanderbilt Memory and Alzheimer's Center, Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Divisions of Cardiovascular and Geriatric Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Timothy J Hohman
- Vanderbilt Memory and Alzheimer's Center, Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - David J Libon
- Department of Geriatrics and Gerontology and Psychology, New Jersey Institute for Successful Aging, School of Osteopathic Medicine, Rowan University, Stratford, New Jersey, USA
| | - Kaj Blennow
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at University of Gothenburg, Mölndal, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at University of Gothenburg, Mölndal, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden.,Department of Molecular Neuroscience, UCL Institute of Neurology, London, United Kingdom.,UK Dementia Research Institute at UCL, London, United Kingdom
| | - Angela L Jefferson
- Vanderbilt Memory and Alzheimer's Center, Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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23
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Moore EE, Hohman TJ, Badami FS, Pechman KR, Osborn KE, Acosta LMY, Bell SP, Babicz MA, Gifford KA, Anderson AW, Goldstein LE, Blennow K, Zetterberg H, Jefferson AL. Neurofilament relates to white matter microstructure in older adults. Neurobiol Aging 2018; 70:233-241. [PMID: 30036759 PMCID: PMC6119102 DOI: 10.1016/j.neurobiolaging.2018.06.023] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 06/14/2018] [Accepted: 06/18/2018] [Indexed: 01/10/2023]
Abstract
Cerebrospinal fluid (CSF) neurofilament light (NFL) is a protein biomarker of axonal injury. To study whether NFL is associated with diffusion tensor imaging (DTI) measurements of white matter (WM) microstructure, Vanderbilt Memory & Aging Project participants with normal cognition (n = 77), early mild cognitive impairment (n = 15), and MCI (n = 55) underwent lumbar puncture to obtain CSF and 3T brain MRI. Voxel-wise analyses cross-sectionally related NFL to DTI metrics, adjusting for demographic and vascular risk factors. Increased NFL correlated with multiple DTI metrics (p-values < 0.05). An NFL × diagnosis interaction (excluding early mild cognitive impairment) on WM microstructure (p-values < 0.05) was detected, with associations strongest among MCI. Multiple NFL × CSF biomarker interactions were detected. Associations between NFL and worse WM metrics were strongest among amyloid-β42-negative, tau-positive, and suspected nonamyloid pathology participants. Findings suggest increased NFL, a biomarker of axonal injury, is correlated with compromised WM microstructure. Results highlight the role of elevated NFL in predicting WM damage in cognitively impaired older adults who are amyloid-negative, tau-positive, or meet suspected nonamyloid pathology criteria.
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Affiliation(s)
- Elizabeth E Moore
- Department of Neurology, Vanderbilt Memory & Alzheimer's Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Timothy J Hohman
- Department of Neurology, Vanderbilt Memory & Alzheimer's Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Faizan S Badami
- Department of Neurology, Vanderbilt Memory & Alzheimer's Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kimberly R Pechman
- Department of Neurology, Vanderbilt Memory & Alzheimer's Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Katie E Osborn
- Department of Neurology, Vanderbilt Memory & Alzheimer's Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Lealani Mae Y Acosta
- Department of Neurology, Vanderbilt Memory & Alzheimer's Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Susan P Bell
- Department of Neurology, Vanderbilt Memory & Alzheimer's Center, Vanderbilt University Medical Center, Nashville, TN, USA; Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Michelle A Babicz
- Department of Neurology, Vanderbilt Memory & Alzheimer's Center, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Psychology, University of Houston, Houston, TX, USA
| | - Katherine A Gifford
- Department of Neurology, Vanderbilt Memory & Alzheimer's Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Adam W Anderson
- Department of Biomedical Engineering, Vanderbilt University, Nashville, TN, USA
| | - Lee E Goldstein
- Departments of Psychiatry, Neurology, Radiology, Pathology & Laboratory Medicine, Biomedical Engineering, Electrical & Computer Engineering, Boston University School of Medicine and College of Engineering, Boston, MA, USA
| | - Kaj Blennow
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at University of Gothenburg, Mölndal, Sweden; Clinical Neurochemistry Lab, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at University of Gothenburg, Mölndal, Sweden; Clinical Neurochemistry Lab, Sahlgrenska University Hospital, Mölndal, Sweden; Department of Molecular Neuroscience, UCL Institute of Neurology, Queen Square, London, UK; UK Dementia Research Institute at UCL, London, UK
| | - Angela L Jefferson
- Department of Neurology, Vanderbilt Memory & Alzheimer's Center, Vanderbilt University Medical Center, Nashville, TN, USA.
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24
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Petersen AW, Shah AS, Simmons SF, Shotwell MS, Jacobsen JML, Myers AP, Mixon AS, Bell SP, Kripalani S, Schnelle JF, Vasilevskis EE. Shed-MEDS: pilot of a patient-centered deprescribing framework reduces medications in hospitalized older adults being transferred to inpatient postacute care. Ther Adv Drug Saf 2018; 9:523-533. [PMID: 30181860 PMCID: PMC6116773 DOI: 10.1177/2042098618781524] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 05/07/2018] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Polypharmacy is common in hospitalized older adults. Deprescribing interventions are not well described in the acute-care setting. The objective of this study was to describe a hospital-based, patient-centered deprescribing protocol (Shed-MEDS) and report pilot results. METHODS This was a pilot study set in one academic medical center in the United States. Participants consisted of a convenience sample of 40 Medicare-eligible, hospitalized patients with at least five prescribed medications. A deprescribing protocol (Shed-MEDS) was implemented among 20 intervention and 20 usual care control patients during their hospital stay. The primary outcome was the total number of medications deprescribed from hospital enrollment. Deprescribed was defined as medication termination or dose reduction. Enrollment medications reflected all prehospital medications and active in-hospital medications. Baseline characteristics and outcomes were compared between the intervention and usual care groups using simple logistic or linear regression for categorical and continuous measures, respectively. RESULTS There was no significant difference between groups in mean age, sex or Charlson comorbidity index. The intervention and control groups had a comparable number of medications at enrollment, 25.2 (±6.3) and 23.4 (±3.8), respectively. The number of prehospital medications in each group was 13.3 (±4.6) and 15.3 (±4.6), respectively. The Shed-MEDS protocol compared with usual care significantly increased the mean number of deprescribed medications at hospital discharge and reduced the total medication burden by 11.6 versus 9.1 (p = 0.032) medications. The deprescribing intervention was associated with a difference of 4.6 [95% confidence interval (CI) 2.5-6.7, p < 0.001] in deprescribed medications and a 0.5 point reduction (95% CI -0.01 to 1.1) in the drug burden index. CONCLUSIONS A hospital-based, patient-centered deprescribing intervention is feasible and may reduce the medication burden in older adults.
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Affiliation(s)
- Alec W. Petersen
- Center for Quality Aging, Vanderbilt University
Medical Center, Nashville, TN, USA
| | - Avantika S. Shah
- Center for Quality Aging, Vanderbilt University
Medical Center, Nashville, TN, USA
| | - Sandra F. Simmons
- Center for Quality Aging, Vanderbilt University
Medical Center, Nashville, TN, USA
- Division of Geriatrics, Vanderbilt University
Medical Center, Nashville, TN, USA
- Geriatric Research Education and Clinical
Center, VA Tennessee Valley Healthcare System, Nashville, TN, USA
| | | | | | - Amy P. Myers
- Pharmaceutical Services, Vanderbilt University
Medical Center, Nashville, TN, USA
| | - Amanda S. Mixon
- Geriatric Research Education and Clinical
Center, VA Tennessee Valley Healthcare System, Nashville, TN, USA
- Section of Hospital Medicine, Vanderbilt
University Medical Center, Nashville, TN, USA
- Center for Clinical Quality and Implementation
Research, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Susan P. Bell
- Center for Quality Aging, Vanderbilt University
Medical Center, Nashville, TN, USA
- Division of Geriatrics, Vanderbilt University
Medical Center, Nashville, TN, USA
- Division of Cardiovascular Medicine, Vanderbilt
University Medical Center, Nashville, TN, USA
| | - Sunil Kripalani
- Section of Hospital Medicine, Vanderbilt
University Medical Center, Nashville, TN, USA
- Center for Clinical Quality and Implementation
Research, Vanderbilt University Medical Center, Nashville, TN, USA
| | - John F. Schnelle
- Center for Quality Aging, Vanderbilt University
Medical Center, Nashville, TN, USA
- Division of Geriatrics, Vanderbilt University
Medical Center, Nashville, TN, USA
- Geriatric Research Education and Clinical
Center, VA Tennessee Valley Healthcare System, Nashville, TN, USA
| | - Eduard E. Vasilevskis
- Vanderbilt Center for Health Services Research,
Center for Quality Aging, Division of General Internal Medicine and Public
Health, Geriatric Research Education and Clinical Center, VA Tennessee
Valley, 2525 West End Ave, Suite 450, Nashville, TN 37203, USA
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25
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Moore EE, Liu D, Pechman KR, Terry JG, Nair S, Cambronero FE, Bell SP, Gifford KA, Anderson AW, Hohman TJ, Carr JJ, Jefferson AL. Increased Left Ventricular Mass Index Is Associated With Compromised White Matter Microstructure Among Older Adults. J Am Heart Assoc 2018; 7:JAHA.118.009041. [PMID: 29945917 PMCID: PMC6064880 DOI: 10.1161/jaha.118.009041] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Background Left ventricular (LV) hypertrophy is associated with cerebrovascular disease and cognitive decline. Increased LV mass index is a subclinical imaging marker that precedes overt LV hypertrophy. This study relates LV mass index to white matter microstructure and cognition among older adults with normal cognition and mild cognitive impairment. Methods and Results Vanderbilt Memory & Aging Project participants free of clinical stroke, dementia, and heart failure (n=318, 73±7 years, 58% male, 39% mild cognitive impairment) underwent brain magnetic resonance imaging, cardiac magnetic resonance, and neuropsychological assessment. Voxelwise analyses related LV mass index (g/m2) to diffusion tensor imaging metrics. Models adjusted for age, sex, education, race/ethnicity, Framingham Stroke Risk Profile, cognitive diagnosis, and apolipoprotein E–ε4 status. Secondary analyses included a LV mass index×diagnosis interaction term with follow‐up models stratified by diagnosis. With identical covariates, linear regression models related LV mass index to neuropsychological performances. Increased LV mass index related to altered white matter microstructure (P<0.05). In models stratified by diagnosis, associations between LV mass index and diffusion tensor imaging were present among mild cognitive impairment participants only (P<0.05). LV mass index was related only to worse visuospatial memory performance (β=−0.003, P=0.036), an observation that would not withstand correction for multiple testing. Conclusions In the absence of prevalent heart failure and clinical stroke, increased LV mass index corresponds to altered white matter microstructure, particularly among older adults with clinical symptoms of prodromal dementia. Findings highlight the potential link between subclinical LV remodeling and cerebral white matter microstructure vulnerability.
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Affiliation(s)
- Elizabeth E Moore
- Department of Neurology, Vanderbilt Memory & Alzheimer's Center, Vanderbilt University Medical Center, Nashville, TN
| | - Dandan Liu
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Kimberly R Pechman
- Department of Neurology, Vanderbilt Memory & Alzheimer's Center, Vanderbilt University Medical Center, Nashville, TN
| | - James G Terry
- Department of Radiology & Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN
| | - Sangeeta Nair
- Department of Radiology & Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN
| | - Francis E Cambronero
- Department of Neurology, Vanderbilt Memory & Alzheimer's Center, Vanderbilt University Medical Center, Nashville, TN
| | - Susan P Bell
- Department of Neurology, Vanderbilt Memory & Alzheimer's Center, Vanderbilt University Medical Center, Nashville, TN.,Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Katherine A Gifford
- Department of Neurology, Vanderbilt Memory & Alzheimer's Center, Vanderbilt University Medical Center, Nashville, TN
| | - Adam W Anderson
- Department of Biomedical Engineering, Vanderbilt University, Nashville, TN
| | - Timothy J Hohman
- Department of Neurology, Vanderbilt Memory & Alzheimer's Center, Vanderbilt University Medical Center, Nashville, TN
| | - John Jeffrey Carr
- Department of Radiology & Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN
| | - Angela L Jefferson
- Department of Neurology, Vanderbilt Memory & Alzheimer's Center, Vanderbilt University Medical Center, Nashville, TN .,Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
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26
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Bradham WS, Bell SP, Huang S, Harrell FE, Adkisson DW, Lawson MA, Sawyer DB, Ooi H, Kronenberg MW. Timing of Left Ventricular Remodeling in Nonischemic Dilated Cardiomyopathy. Am J Med Sci 2018; 356:262-267. [PMID: 30286821 DOI: 10.1016/j.amjms.2018.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 06/01/2018] [Indexed: 10/14/2022]
Abstract
BACKGROUND Mineralocorticoid receptor antagonist (MRA) treatment produces beneficial left ventricular (LV) remodeling in nonischemic dilated cardiomyopathy (NIDCM). This study addressed the timing of maximal beneficial LV remodeling in NIDCM when adding MRA. MATERIALS AND METHODS We studied 12 patients with NIDCM on stable β-blocker and angiotensin-converting enzyme inhibitor/angiotensin receptor-blocking therapy who underwent cardiac magnetic resonance imaging before and after 6-31 months of continuous MRA therapy. RESULTS At baseline, the LV ejection fraction (LVEF) was 24% (19-27); median [interquartile range]. The LV end-systolic volume index (LVESVI) was 63 ml (57-76) and the LV stroke volume index (LVSVI) was 19 ml (14-21), all depressed. After adding MRA to the HF regimen, the LVEF increased to 47% (42-52), with a decrease in LVESVI to 36 ml (33-45) and increase in LVSVI to 36 ml (28-39) (for each, P < 0 .0001). Using generalized least squares analysis, the maximal beneficial remodeling (defined by maximal increase in LVEF, the maximal decrease in LVESVI and maximal increase in LVSVI) was achieved after approximately 12-16 months of MRA treatment. CONCLUSIONS Adding MRA to a standard medical regimen for NIDCM resulted in beneficial LV remodeling. The maximal beneficial remodeling was achieved with 12-16 months of MRA therapy. These results have implications for the timing of other advanced therapies, such as placing internal cardioverter-defibrillators.
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Affiliation(s)
| | | | - Shi Huang
- Department of Biostatistics, Vanderbilt University School of Medicine, and the Cardiology Section, VA Tennessee Valley Healthcare System, Nashville, Tennessee
| | - Frank E Harrell
- Department of Biostatistics, Vanderbilt University School of Medicine, and the Cardiology Section, VA Tennessee Valley Healthcare System, Nashville, Tennessee
| | | | | | | | - Henry Ooi
- Division of Cardiovascular Medicine and
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27
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Gifford KA, Liu D, Neal JE, Acosta LMY, Bell SP, Wiggins ME, Wisniewski KM, Godfrey M, Logan LA, Hohman TJ, Pechman KR, Libon DJ, Blennow K, Zetterberg H, Jefferson AL. Validity and Normative Data for the Biber Figure Learning Test: A Visual Supraspan Memory Measure. Assessment 2018; 27:1320-1334. [PMID: 29809069 DOI: 10.1177/1073191118773870] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The Biber Figure Learning Test (BFLT), a visuospatial serial figure learning test, was evaluated for biological correlates and psychometric properties, and normative data were generated. Nondemented individuals (n = 332, 73 ± 7, 41% female) from the Vanderbilt Memory & Aging Project completed a comprehensive neuropsychological protocol. Adjusted regression models related BFLT indices to structural brain magnetic resonance imaging and cerebrospinal fluid (CSF) markers of brain health. Regression-based normative data were generated. Lower BFLT performances (Total Learning, Delayed Recall, Recognition) related to smaller medial temporal lobe volumes and higher CSF tau concentrations but not CSF amyloid. BFLT indices were most strongly correlated with other measures of verbal and nonverbal memory and visuospatial skills. The BFLT provides a comprehensive assessment of all aspects of visuospatial learning and memory and is sensitive to biomarkers of unhealthy brain aging. Enhanced normative data enriches the clinical utility of this visual serial figure learning test for use with older adults.
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Affiliation(s)
| | - Dandan Liu
- Vanderbilt University Medical Center, Nashville, TN, USA
| | | | | | - Susan P Bell
- Vanderbilt University Medical Center, Nashville, TN, USA
| | | | | | | | - Laura A Logan
- Vanderbilt University Medical Center, Nashville, TN, USA
| | | | | | | | - Kaj Blennow
- University of Gothenburg, Mölndal, Sweden.,Sahlgrenska University Hospital, Mölndal, Sweden
| | - Henrik Zetterberg
- University of Gothenburg, Mölndal, Sweden.,Sahlgrenska University Hospital, Mölndal, Sweden.,UCL Institute of Neurology, Queen Square, London, UK.,UK Dementia Research Institute at UCL, London, UK
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Forman DE, Maurer MS, Boyd C, Brindis R, Salive ME, Horne FM, Bell SP, Fulmer T, Reuben DB, Zieman S, Rich MW. Multimorbidity in Older Adults With Cardiovascular Disease. J Am Coll Cardiol 2018; 71:2149-2161. [PMID: 29747836 PMCID: PMC6028235 DOI: 10.1016/j.jacc.2018.03.022] [Citation(s) in RCA: 174] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 02/26/2018] [Accepted: 03/01/2018] [Indexed: 11/19/2022]
Abstract
Multimorbidity occurs in adults of all ages, but the number and complexity of comorbid conditions commonly increase with advancing age such that cardiovascular disease (CVD) in older adults typically occurs in a context of multimorbidity. Current clinical practice and research mainly target single disease-specific care that does not embrace the complexities imposed by concurrent conditions. In this paper, emerging concepts regarding CVD in combination with multimorbidity are reviewed, including recommendations for incorporating multimorbidity into clinical decision making, critical knowledge gaps, and research priorities to optimize care of complex older patients.
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Affiliation(s)
- Daniel E Forman
- Department of Medicine, Section of Geriatric Cardiology, Veterans Affairs Geriatric Research Education, and Clinical Center, University of Pittsburgh, Pittsburgh, Pennsylvania.
| | - Mathew S Maurer
- Department of Medicine, Division of Cardiology, Columbia University Medical Center, New York, New York
| | - Cynthia Boyd
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ralph Brindis
- Phillip R. Lee Institute for Health Policy Studies, University of California-San Francisco, San Francisco, California
| | - Marcel E Salive
- Division of Geriatrics and Clinical Gerontology, National Institute on Aging, Bethesda, Maryland
| | | | - Susan P Bell
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - David B Reuben
- Division of Geriatrics, David Geffen School of Medicine at University of California-Los Angeles, Los Angeles, California
| | - Susan Zieman
- Division of Geriatrics and Clinical Gerontology, National Institute on Aging, Bethesda, Maryland
| | - Michael W Rich
- Division of Cardiology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
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29
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Osborn KE, Liu D, Samuels LR, Moore EE, Cambronero FE, Acosta LMY, Bell SP, Babicz MA, Gordon EA, Pechman KR, Davis LT, Gifford KA, Hohman TJ, Blennow K, Zetterberg H, Jefferson AL. Cerebrospinal fluid β-amyloid 42 and neurofilament light relate to white matter hyperintensities. Neurobiol Aging 2018; 68:18-25. [PMID: 29702372 DOI: 10.1016/j.neurobiolaging.2018.03.028] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 03/20/2018] [Accepted: 03/27/2018] [Indexed: 12/12/2022]
Abstract
White matter hyperintensities (WMHs) are associated with poorer brain health, but their pathophysiological substrates remain elusive. To better understand the mechanistic underpinnings of WMHs among older adults, this study examined in vivo cerebrospinal fluid biomarkers of β-amyloid42 deposition (Aβ42), hyperphosphorylated tau pathology, neurodegeneration (total tau), and axonal injury (neurofilament light [NFL]) in relation to log-transformed WMHs volume. Participants free of clinical stroke and dementia were drawn from the Vanderbilt Memory & Aging Project (n = 148, 72 ± 6 years). Linear regression models adjusted for age, sex, race/ethnicity, education, intracranial volume, modified Framingham Stroke Risk Profile (excluding points assigned for age), cognitive diagnosis, and APOE-ε4 carrier status. Aβ42 (β = -0.001, p = 0.007) and NFL (β = 0.0003, p = 0.01) concentrations related to WMHs but neither hyperphosphorylated tau nor total tau associations with WMHs reached statistical significance (p-values > 0.21). In a combined model, NFL accounted for 3.2% of unique variance in WMHs and Aβ42 accounted for an additional 4.3% beyond NFL, providing novel evidence of the co-occurrence of at least 2 distinct pathways for WMHs among older adults, including amyloid deposition and axonal injury.
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Affiliation(s)
- Katie E Osborn
- Vanderbilt Memory & Alzheimer's Center, Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Dandan Liu
- Vanderbilt Memory & Alzheimer's Center, Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Lauren R Samuels
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Elizabeth E Moore
- Vanderbilt Memory & Alzheimer's Center, Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Francis E Cambronero
- Vanderbilt Memory & Alzheimer's Center, Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Lealani Mae Y Acosta
- Vanderbilt Memory & Alzheimer's Center, Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Susan P Bell
- Vanderbilt Memory & Alzheimer's Center, Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA; Divisions of Cardiovascular and Geriatric Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Michelle A Babicz
- Vanderbilt Memory & Alzheimer's Center, Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Elizabeth A Gordon
- Vanderbilt Memory & Alzheimer's Center, Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kimberly R Pechman
- Vanderbilt Memory & Alzheimer's Center, Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - L Taylor Davis
- Radiology & Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Katherine A Gifford
- Vanderbilt Memory & Alzheimer's Center, Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Timothy J Hohman
- Vanderbilt Memory & Alzheimer's Center, Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kaj Blennow
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at University of Gothenburg, Mölndal, Sweden
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at University of Gothenburg, Mölndal, Sweden
| | - Angela L Jefferson
- Vanderbilt Memory & Alzheimer's Center, Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA.
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30
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Kresge HA, Khan OA, Wagener MA, Liu D, Terry JG, Nair S, Cambronero FE, Gifford KA, Osborn KE, Hohman TJ, Pechman KR, Bell SP, Wang TJ, Carr JJ, Jefferson AL. Subclinical Compromise in Cardiac Strain Relates to Lower Cognitive Performances in Older Adults. J Am Heart Assoc 2018; 7:JAHA.117.007562. [PMID: 29440034 PMCID: PMC5850190 DOI: 10.1161/jaha.117.007562] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Global longitudinal strain (GLS), reflecting total shortening of the myocardium during the cardiac cycle, has emerged as a more precise myocardial function measure than left ventricular ejection fraction (LVEF). Longitudinal strain may be selectively affected in subclinical heart disease, even in the presence of normal LVEF. This study examines subclinical cardiac dysfunction, assessed by GLS and LVEF, and cognition among older adults. METHODS AND RESULTS Vanderbilt Memory and Aging Project participants who were free of clinical dementia, stroke, and heart failure (n=318, 73±7 years, 58% male) completed neuropsychological assessment and cardiac magnetic resonance to quantify GLS and LVEF. Linear regression models related GLS and LVEF to neuropsychological performances, adjusting for age, sex, race/ethnicity, education, Framingham Stroke Risk Profile, cognitive diagnosis, and APOE*ε4 status. Models were repeated with a cardiac×cognitive diagnosis interaction term. Compromised GLS (reflected by higher values) related to worse naming (β=-0.07, P=0.04), visuospatial immediate recall (β=-0.83, P=0.03), visuospatial delayed recall (β=-0.22, P=0.03), and verbal delayed recall (β=-0.11, P=0.007). LVEF did not relate to worse performance on any measure (P>0.18). No diagnostic interactions were observed. CONCLUSIONS Our study results are among the first to suggest that compromised GLS relates to worse episodic memory and language performance among older adults who are free of clinical dementia, stroke, and heart failure. Subclinical cardiac dysfunction may correlate with cognitive health in late life, even when LVEF remains normal. The results add to growing evidence that GLS may be a more sensitive and preferred method for quantifying subclinical changes in cardiac function.
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Affiliation(s)
- Hailey A Kresge
- Department of Neurology, Vanderbilt Memory & Alzheimer's Center Vanderbilt University Medical Center, Nashville, TN
| | - Omair A Khan
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Madison A Wagener
- Department of Neurology, Vanderbilt Memory & Alzheimer's Center Vanderbilt University Medical Center, Nashville, TN
- Department of Psychology, Vanderbilt University, Nashville, TN
| | - Dandan Liu
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - James G Terry
- Radiology& Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN
| | - Sangeeta Nair
- Radiology& Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN
| | - Francis E Cambronero
- Department of Neurology, Vanderbilt Memory & Alzheimer's Center Vanderbilt University Medical Center, Nashville, TN
| | - Katherine A Gifford
- Department of Neurology, Vanderbilt Memory & Alzheimer's Center Vanderbilt University Medical Center, Nashville, TN
| | - Katie E Osborn
- Department of Neurology, Vanderbilt Memory & Alzheimer's Center Vanderbilt University Medical Center, Nashville, TN
| | - Timothy J Hohman
- Department of Neurology, Vanderbilt Memory & Alzheimer's Center Vanderbilt University Medical Center, Nashville, TN
| | - Kimberly R Pechman
- Department of Neurology, Vanderbilt Memory & Alzheimer's Center Vanderbilt University Medical Center, Nashville, TN
| | - Susan P Bell
- Department of Neurology, Vanderbilt Memory & Alzheimer's Center Vanderbilt University Medical Center, Nashville, TN
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Division of General Internal Medicine, Department of Medicine, Center for Quality Aging, Vanderbilt University Medical Center, Nashville, TN
| | - Thomas J Wang
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - John Jeffrey Carr
- Radiology& Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Angela L Jefferson
- Department of Neurology, Vanderbilt Memory & Alzheimer's Center Vanderbilt University Medical Center, Nashville, TN
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
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31
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Jefferson AL, Liu D, Gupta DK, Pechman KR, Watchmaker JM, Gordon EA, Rane S, Bell SP, Mendes LA, Davis LT, Gifford KA, Hohman TJ, Wang TJ, Donahue MJ. Lower cardiac index levels relate to lower cerebral blood flow in older adults. Neurology 2017; 89:2327-2334. [PMID: 29117962 DOI: 10.1212/wnl.0000000000004707] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Accepted: 09/18/2017] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVE To assess cross-sectionally whether lower cardiac index relates to lower resting cerebral blood flow (CBF) and cerebrovascular reactivity (CVR) among older adults. METHODS Vanderbilt Memory & Aging Project participants free of stroke, dementia, and heart failure were studied (n = 314, age 73 ± 7 years, 59% male, 39% with mild cognitive impairment). Cardiac index (liters per minute per meter squared) was quantified from echocardiography. Resting CBF (milliliters per 100 grams per minute) and hypercapnia-induced CVR were quantified from pseudo-continuous arterial spin-labeling MRI. Linear regressions with ordinary least-square estimates related cardiac index to regional CBF, with adjustment for age, education, race/ethnicity, Framingham Stroke Risk Profile score (systolic blood pressure, antihypertensive medication use, diabetes mellitus, current cigarette smoking, left ventricular hypertrophy, prevalent cardiovascular disease [CVD], atrial fibrillation), APOE ε4 status, cognitive diagnosis, and regional tissue volume. RESULTS Lower cardiac index corresponded to lower resting CBF in the left (β = 2.4, p = 0.001) and right (β = 2.5, p = 0.001) temporal lobes. Results were similar when participants with prevalent CVD and atrial fibrillation were excluded (left temporal lobe β = 2.3, p = 0.003; right temporal lobe β = 2.5, p = 0.003). Cardiac index was unrelated to CBF in other regions assessed (p > 0.25) and CVR in all regions (p > 0.05). In secondary cardiac index × cognitive diagnosis interaction models, cardiac index and CBF associations were present only in cognitively normal participants and affected a majority of regions assessed with effects strongest in the left (p < 0.0001) and right (p < 0.0001) temporal lobes. CONCLUSIONS Among older adults without stroke, dementia, or heart failure, systemic blood flow correlates with cerebral CBF in the temporal lobe, independently of prevalent CVD, but not CVR.
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Affiliation(s)
- Angela L Jefferson
- From the Vanderbilt Memory & Alzheimer's Center (A.L.J., K.R.P., E.A.G., S.P.B., K.A.G., T.J.H., M.J.D.), Department of Neurology, Department of Biostatistics (D.L.), Division of Cardiovascular Medicine (D.K.G., S.P.B., L.A.M., T.J.W.), Department of Medicine, Division of General Internal Medicine, Center for Quality Aging (S.P.B.), Radiology & Radiological Sciences (L.T.D., M.J.D.), and Department of Psychiatry (M.J.D.), Vanderbilt University Medical Center; Vanderbilt University Institute of Imaging Science (J.M.W., M.J.D.), Nashville, TN; and Radiology (S.R.), University of Washington Medical Center, Seattle.
| | - Dandan Liu
- From the Vanderbilt Memory & Alzheimer's Center (A.L.J., K.R.P., E.A.G., S.P.B., K.A.G., T.J.H., M.J.D.), Department of Neurology, Department of Biostatistics (D.L.), Division of Cardiovascular Medicine (D.K.G., S.P.B., L.A.M., T.J.W.), Department of Medicine, Division of General Internal Medicine, Center for Quality Aging (S.P.B.), Radiology & Radiological Sciences (L.T.D., M.J.D.), and Department of Psychiatry (M.J.D.), Vanderbilt University Medical Center; Vanderbilt University Institute of Imaging Science (J.M.W., M.J.D.), Nashville, TN; and Radiology (S.R.), University of Washington Medical Center, Seattle
| | - Deepak K Gupta
- From the Vanderbilt Memory & Alzheimer's Center (A.L.J., K.R.P., E.A.G., S.P.B., K.A.G., T.J.H., M.J.D.), Department of Neurology, Department of Biostatistics (D.L.), Division of Cardiovascular Medicine (D.K.G., S.P.B., L.A.M., T.J.W.), Department of Medicine, Division of General Internal Medicine, Center for Quality Aging (S.P.B.), Radiology & Radiological Sciences (L.T.D., M.J.D.), and Department of Psychiatry (M.J.D.), Vanderbilt University Medical Center; Vanderbilt University Institute of Imaging Science (J.M.W., M.J.D.), Nashville, TN; and Radiology (S.R.), University of Washington Medical Center, Seattle
| | - Kimberly R Pechman
- From the Vanderbilt Memory & Alzheimer's Center (A.L.J., K.R.P., E.A.G., S.P.B., K.A.G., T.J.H., M.J.D.), Department of Neurology, Department of Biostatistics (D.L.), Division of Cardiovascular Medicine (D.K.G., S.P.B., L.A.M., T.J.W.), Department of Medicine, Division of General Internal Medicine, Center for Quality Aging (S.P.B.), Radiology & Radiological Sciences (L.T.D., M.J.D.), and Department of Psychiatry (M.J.D.), Vanderbilt University Medical Center; Vanderbilt University Institute of Imaging Science (J.M.W., M.J.D.), Nashville, TN; and Radiology (S.R.), University of Washington Medical Center, Seattle
| | - Jennifer M Watchmaker
- From the Vanderbilt Memory & Alzheimer's Center (A.L.J., K.R.P., E.A.G., S.P.B., K.A.G., T.J.H., M.J.D.), Department of Neurology, Department of Biostatistics (D.L.), Division of Cardiovascular Medicine (D.K.G., S.P.B., L.A.M., T.J.W.), Department of Medicine, Division of General Internal Medicine, Center for Quality Aging (S.P.B.), Radiology & Radiological Sciences (L.T.D., M.J.D.), and Department of Psychiatry (M.J.D.), Vanderbilt University Medical Center; Vanderbilt University Institute of Imaging Science (J.M.W., M.J.D.), Nashville, TN; and Radiology (S.R.), University of Washington Medical Center, Seattle
| | - Elizabeth A Gordon
- From the Vanderbilt Memory & Alzheimer's Center (A.L.J., K.R.P., E.A.G., S.P.B., K.A.G., T.J.H., M.J.D.), Department of Neurology, Department of Biostatistics (D.L.), Division of Cardiovascular Medicine (D.K.G., S.P.B., L.A.M., T.J.W.), Department of Medicine, Division of General Internal Medicine, Center for Quality Aging (S.P.B.), Radiology & Radiological Sciences (L.T.D., M.J.D.), and Department of Psychiatry (M.J.D.), Vanderbilt University Medical Center; Vanderbilt University Institute of Imaging Science (J.M.W., M.J.D.), Nashville, TN; and Radiology (S.R.), University of Washington Medical Center, Seattle
| | - Swati Rane
- From the Vanderbilt Memory & Alzheimer's Center (A.L.J., K.R.P., E.A.G., S.P.B., K.A.G., T.J.H., M.J.D.), Department of Neurology, Department of Biostatistics (D.L.), Division of Cardiovascular Medicine (D.K.G., S.P.B., L.A.M., T.J.W.), Department of Medicine, Division of General Internal Medicine, Center for Quality Aging (S.P.B.), Radiology & Radiological Sciences (L.T.D., M.J.D.), and Department of Psychiatry (M.J.D.), Vanderbilt University Medical Center; Vanderbilt University Institute of Imaging Science (J.M.W., M.J.D.), Nashville, TN; and Radiology (S.R.), University of Washington Medical Center, Seattle
| | - Susan P Bell
- From the Vanderbilt Memory & Alzheimer's Center (A.L.J., K.R.P., E.A.G., S.P.B., K.A.G., T.J.H., M.J.D.), Department of Neurology, Department of Biostatistics (D.L.), Division of Cardiovascular Medicine (D.K.G., S.P.B., L.A.M., T.J.W.), Department of Medicine, Division of General Internal Medicine, Center for Quality Aging (S.P.B.), Radiology & Radiological Sciences (L.T.D., M.J.D.), and Department of Psychiatry (M.J.D.), Vanderbilt University Medical Center; Vanderbilt University Institute of Imaging Science (J.M.W., M.J.D.), Nashville, TN; and Radiology (S.R.), University of Washington Medical Center, Seattle
| | - Lisa A Mendes
- From the Vanderbilt Memory & Alzheimer's Center (A.L.J., K.R.P., E.A.G., S.P.B., K.A.G., T.J.H., M.J.D.), Department of Neurology, Department of Biostatistics (D.L.), Division of Cardiovascular Medicine (D.K.G., S.P.B., L.A.M., T.J.W.), Department of Medicine, Division of General Internal Medicine, Center for Quality Aging (S.P.B.), Radiology & Radiological Sciences (L.T.D., M.J.D.), and Department of Psychiatry (M.J.D.), Vanderbilt University Medical Center; Vanderbilt University Institute of Imaging Science (J.M.W., M.J.D.), Nashville, TN; and Radiology (S.R.), University of Washington Medical Center, Seattle
| | - L Taylor Davis
- From the Vanderbilt Memory & Alzheimer's Center (A.L.J., K.R.P., E.A.G., S.P.B., K.A.G., T.J.H., M.J.D.), Department of Neurology, Department of Biostatistics (D.L.), Division of Cardiovascular Medicine (D.K.G., S.P.B., L.A.M., T.J.W.), Department of Medicine, Division of General Internal Medicine, Center for Quality Aging (S.P.B.), Radiology & Radiological Sciences (L.T.D., M.J.D.), and Department of Psychiatry (M.J.D.), Vanderbilt University Medical Center; Vanderbilt University Institute of Imaging Science (J.M.W., M.J.D.), Nashville, TN; and Radiology (S.R.), University of Washington Medical Center, Seattle
| | - Katherine A Gifford
- From the Vanderbilt Memory & Alzheimer's Center (A.L.J., K.R.P., E.A.G., S.P.B., K.A.G., T.J.H., M.J.D.), Department of Neurology, Department of Biostatistics (D.L.), Division of Cardiovascular Medicine (D.K.G., S.P.B., L.A.M., T.J.W.), Department of Medicine, Division of General Internal Medicine, Center for Quality Aging (S.P.B.), Radiology & Radiological Sciences (L.T.D., M.J.D.), and Department of Psychiatry (M.J.D.), Vanderbilt University Medical Center; Vanderbilt University Institute of Imaging Science (J.M.W., M.J.D.), Nashville, TN; and Radiology (S.R.), University of Washington Medical Center, Seattle
| | - Timothy J Hohman
- From the Vanderbilt Memory & Alzheimer's Center (A.L.J., K.R.P., E.A.G., S.P.B., K.A.G., T.J.H., M.J.D.), Department of Neurology, Department of Biostatistics (D.L.), Division of Cardiovascular Medicine (D.K.G., S.P.B., L.A.M., T.J.W.), Department of Medicine, Division of General Internal Medicine, Center for Quality Aging (S.P.B.), Radiology & Radiological Sciences (L.T.D., M.J.D.), and Department of Psychiatry (M.J.D.), Vanderbilt University Medical Center; Vanderbilt University Institute of Imaging Science (J.M.W., M.J.D.), Nashville, TN; and Radiology (S.R.), University of Washington Medical Center, Seattle
| | - Thomas J Wang
- From the Vanderbilt Memory & Alzheimer's Center (A.L.J., K.R.P., E.A.G., S.P.B., K.A.G., T.J.H., M.J.D.), Department of Neurology, Department of Biostatistics (D.L.), Division of Cardiovascular Medicine (D.K.G., S.P.B., L.A.M., T.J.W.), Department of Medicine, Division of General Internal Medicine, Center for Quality Aging (S.P.B.), Radiology & Radiological Sciences (L.T.D., M.J.D.), and Department of Psychiatry (M.J.D.), Vanderbilt University Medical Center; Vanderbilt University Institute of Imaging Science (J.M.W., M.J.D.), Nashville, TN; and Radiology (S.R.), University of Washington Medical Center, Seattle
| | - Manus J Donahue
- From the Vanderbilt Memory & Alzheimer's Center (A.L.J., K.R.P., E.A.G., S.P.B., K.A.G., T.J.H., M.J.D.), Department of Neurology, Department of Biostatistics (D.L.), Division of Cardiovascular Medicine (D.K.G., S.P.B., L.A.M., T.J.W.), Department of Medicine, Division of General Internal Medicine, Center for Quality Aging (S.P.B.), Radiology & Radiological Sciences (L.T.D., M.J.D.), and Department of Psychiatry (M.J.D.), Vanderbilt University Medical Center; Vanderbilt University Institute of Imaging Science (J.M.W., M.J.D.), Nashville, TN; and Radiology (S.R.), University of Washington Medical Center, Seattle
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Abstract
Multimorbidity is the most significant condition affecting older adults, and it impacts every component of health care management and delivery. Multimorbidity significantly increases with age. For individuals with a diagnosis of cardiovascular disease, multimorbidity has a significant effect on the presentation of the disease and the diagnosis, management, and patient-centered preferences in care. Evidence-based therapeutics have focused on cardiovascular focused morbidity. Over the next 25 years, the proportion of adults aged 65 and older is estimated to increase three-fold. The needs of these patients require a fundamental shift in care from single disease practices to a more patient-centered framework.
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Affiliation(s)
- Susan P Bell
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medicine Center, Nashville, TN, USA; Division of Geriatric Medicine, Center for Quality Aging, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Avantika A Saraf
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medicine Center, Nashville, TN, USA; Division of Geriatric Medicine, Center for Quality Aging, Vanderbilt University Medical Center, Nashville, TN, USA
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33
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Brummel NE, Bell SP, Girard TD, Pandharipande PP, Jackson JC, Morandi A, Thompson JL, Chandrasekhar R, Bernard GR, Dittus RS, Gill TM, Ely EW. Frailty and Subsequent Disability and Mortality among Patients with Critical Illness. Am J Respir Crit Care Med 2017; 196:64-72. [PMID: 27922747 DOI: 10.1164/rccm.201605-0939oc] [Citation(s) in RCA: 182] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
RATIONALE The prevalence of frailty (diminished physiologic reserve) and its effect on outcomes for those aged 18 years and older with critical illness is unclear. OBJECTIVES We hypothesized greater frailty would be associated with subsequent mortality, disability, and cognitive impairment, regardless of age. METHODS At enrollment, we measured frailty using the Clinical Frailty Scale (range, 1 [very fit] to 7 [severely frail]). At 3 and 12 months post-discharge, we assessed vital status, instrumental activities of daily living, basic activities of daily living, and cognition. We used multivariable regression to analyze associations between Clinical Frailty Scale scores and outcomes, adjusting for age, sex, education, comorbidities, baseline disability, baseline cognition, severity of illness, delirium, coma, sepsis, mechanical ventilation, and sedatives/opiates. MEASUREMENTS AND MAIN RESULTS We enrolled 1,040 patients who were a median (interquartile range) of 62 (53-72) years old and who had a median Clinical Frailty Scale score of 3 (3-5). Half of those with clinical frailty (i.e., Clinical Frailty Scale score ≥5) were younger than 65 years old. Greater Clinical Frailty Scale scores were independently associated with greater mortality (P = 0.01 at 3 mo and P < 0.001 at 12 mo) and with greater odds of disability in instrumental activities of daily living (P = 0.04 at 3 mo and P = 0.002 at 12 mo). Clinical Frailty Scale scores were not associated with disability in basic activities of daily living or with cognition. CONCLUSIONS Frailty is common in critically ill adults aged 18 years and older and is independently associated with increased mortality and greater disability. Future studies should explore routine screening for clinical frailty in critically ill patients of all ages. Interventions to reduce mortality and disability among patients with heightened vulnerability should be developed and tested. Clinical trial registered with www.clinicaltrials.gov (NCT 00392795 and NCT 00400062).
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Affiliation(s)
- Nathan E Brummel
- 1 Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine.,2 Center for Health Services Research.,3 Center for Quality Aging
| | - Susan P Bell
- 3 Center for Quality Aging.,4 Division of Cardiovascular Medicine.,5 Vanderbilt Memory & Alzheimer's Center
| | - Timothy D Girard
- 6 Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | - James C Jackson
- 1 Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine.,2 Center for Health Services Research.,8 Department of Psychiatry and Behavioral Sciences, and.,9 Research Service and
| | - Alessandro Morandi
- 10 Geriatric Research Group, Brescia, Italy.,11 Department of Rehabilitation and Aged Care, Hospital Ancelle, Cremona, Italy; and
| | - Jennifer L Thompson
- 12 Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Rameela Chandrasekhar
- 12 Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Gordon R Bernard
- 1 Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine
| | - Robert S Dittus
- 2 Center for Health Services Research.,13 Geriatric Research, Education and Clinical Center Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee
| | - Thomas M Gill
- 14 Department of Internal Medicine, School of Medicine, Yale University, New Haven, Connecticut
| | - E Wesley Ely
- 1 Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine.,2 Center for Health Services Research.,3 Center for Quality Aging.,13 Geriatric Research, Education and Clinical Center Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee
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Jefferson AL, Gifford KA, Acosta LMY, Bell SP, Donahue MJ, Davis LT, Gottlieb J, Gupta DK, Hohman TJ, Lane EM, Libon DJ, Mendes LA, Niswender K, Pechman KR, Rane S, Ruberg FL, Su YR, Zetterberg H, Liu D. The Vanderbilt Memory & Aging Project: Study Design and Baseline Cohort Overview. J Alzheimers Dis 2017; 52:539-59. [PMID: 26967211 DOI: 10.3233/jad-150914] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Vascular health factors frequently co-occur with Alzheimer's disease (AD). A better understanding of how systemic vascular and cerebrovascular health intersects with clinical and pathological AD may inform prevention and treatment opportunities. OBJECTIVE To establish the Vanderbilt Memory & Aging Project, a case-control longitudinal study investigating vascular health and brain aging, and describe baseline methodology and participant characteristics. METHODS From September 2012 to November 2014, 335 participants age 60- 92 were enrolled, including 168 individuals with mild cognitive impairment (MCI, 73±8 years, 41% female) and 167 age-, sex-, and race-matched cognitively normal controls (NC, 72±7 years, 41% female). At baseline, participants completed a physical and frailty examination, fasting blood draw, neuropsychological assessment, echocardiogram, cardiac MRI, and brain MRI. A subset underwent 24-hour ambulatory blood pressure monitoring and lumbar puncture for cerebrospinal fluid (CSF) collection. RESULTS As designed, participant groups were comparable for age (p = 0.31), sex (p = 0.95), and race (p = 0.65). MCI participants had greater Framingham Stroke Risk Profile scores (p = 0.008), systolic blood pressure values (p = 0.008), and history of left ventricular hypertrophy (p = 0.04) than NC participants. As expected, MCI participants performed worse on all neuropsychological measures (p-values < 0.001), were more likely to be APOEɛ4 carriers (p = 0.02), and had enhanced CSF biomarkers, including lower Aβ42 (p = 0.02), higher total tau (p = 0.004), and higher p-tau (p = 0.02) compared to NC participants. CONCLUSION Diverse sources of baseline and longitudinal data will provide rich opportunities to investigate pathways linking vascular and cerebrovascular health, clinical and pathological AD, and neurodegeneration contributing to novel strategies to delay or prevent cognitive decline.
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Affiliation(s)
- Angela L Jefferson
- Vanderbilt Memory & Alzheimer's Center, Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Katherine A Gifford
- Vanderbilt Memory & Alzheimer's Center, Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Lealani Mae Y Acosta
- Vanderbilt Memory & Alzheimer's Center, Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Susan P Bell
- Vanderbilt Memory & Alzheimer's Center, Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA.,Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.,Center for Quality Aging, Division of General Internal Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Manus J Donahue
- Department of Neurology, Department of Psychiatry, Vanderbilt University Medical Center, Nashville, TN, USA.,Radiology & Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, USA
| | - L Taylor Davis
- Radiology & Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, USA
| | - JoAnn Gottlieb
- Vanderbilt Institute for Clinical & Translational Research, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Deepak K Gupta
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Timothy J Hohman
- Vanderbilt Memory & Alzheimer's Center, Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Elizabeth M Lane
- Vanderbilt Memory & Alzheimer's Center, Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - David J Libon
- Rowan University - School of Osteopathic Medicine, Department of Geriatrics and Gerontology, New Jersey Institute for Successful Aging, Stratford, NJ, USA
| | - Lisa A Mendes
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kevin Niswender
- Tennessee Valley Healthcare System, Division of Diabetes, Endocrinology, & Metabolism, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kimberly R Pechman
- Vanderbilt Memory & Alzheimer's Center, Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Swati Rane
- Radiology, University of Washington Medical Center, Seattle, WA, USA
| | - Frederick L Ruberg
- Boston University School of Medicine, Boston, MA, USA.,Section of Cardiovascular Medicine, Boston Medical Center, Boston, MA, USA
| | - Yan Ru Su
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at University of Gothenburg, Mölndal, Sweden.,Deparment of Molecular Neuroscience, UCL Institute of Neurology, Queen Square, London, UK
| | - Dandan Liu
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
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Bell SP, Liu D, Samuels LR, Saraf AA, Gifford KA, Hohman TJ, Jefferson AL. Late-Life Body Mass Index, Rapid Weight Loss, Apolipoprotein E ε4 and the Risk of Cognitive Decline and Incident Dementia. J Nutr Health Aging 2017; 21:1259-1267. [PMID: 29188888 PMCID: PMC5736008 DOI: 10.1007/s12603-017-0906-3] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To examine the effect of late-life body mass index (BMI) and rapid weight loss on incident mild cognitive impairment (MCI) and Alzheimer's disease (AD). DESIGN Prospective longitudinal cohort study. SETTING National Alzheimer's Coordinating Center (NACC) Uniform Data Set, including 34 past and current National Institute on Aging-funded AD Centers across the United States. PARTICIPANTS 6940 older adults (n=5061 normal cognition [NC]; n=1879 MCI). MEASUREMENTS BMI (kg/m2) and modified Framingham Stroke Risk Profile (FSRP) score (sex, age, systolic blood pressure, anti-hypertension medication, diabetes mellitus, cigarette smoking, prevalent cardiovascular disease, atrial fibrillation) were assessed at baseline. Cognition and weight were assessed annually. RESULTS Multivariable binary logistic regression, adjusting for age, sex, race, education, length of follow-up, and modified FSRP related late-life BMI to risk of diagnostic conversion from NC to MCI or AD and from MCI to AD. Secondary analyses related late-life BMI to diagnostic conversion in the presence of rapid weight loss (>5% decrease in 12 months) and apolipoprotein E (APOE) ε4. During a mean 3.8-year follow-up period, 12% of NC participants converted to MCI or AD and 49% of MCI participants converted to AD. Higher baseline BMI was associated with a reduced probability of diagnostic conversion, such that for each one-unit increase in baseline BMI there was a reduction in diagnostic conversion for both NC (OR=0.977, 95%CI 0.958-0.996, p=0.015) and MCI participants (OR=0.962, 95%CI 0.942-0.983, p<0.001). The protective effect of higher baseline BMI did not persist in the setting of rapid weight loss but did persist when adjusting for APOE ε4. CONCLUSIONS Higher late-life BMI is associated with a lower risk of incident MCI and AD but is not protective in the presence of rapid weight loss.
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Affiliation(s)
- Susan P. Bell
- Vanderbilt Memory & Alzheimer’s Center, Department of Neurology, Vanderbilt University Medical Center, Nashville, TN
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Center for Quality Aging, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Dandan Liu
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN
| | - Lauren R. Samuels
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN
| | - Avantika A. Saraf
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Center for Quality Aging, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Katherine A. Gifford
- Vanderbilt Memory & Alzheimer’s Center, Department of Neurology, Vanderbilt University Medical Center, Nashville, TN
| | - Timothy J. Hohman
- Vanderbilt Memory & Alzheimer’s Center, Department of Neurology, Vanderbilt University Medical Center, Nashville, TN
| | - Angela L. Jefferson
- Vanderbilt Memory & Alzheimer’s Center, Department of Neurology, Vanderbilt University Medical Center, Nashville, TN
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
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Vasilevskis EE, Ouslander JG, Mixon AS, Bell SP, Jacobsen JML, Saraf AA, Markley D, Sponsler KC, Shutes J, Long EA, Kripalani S, Simmons SF, Schnelle JF. Potentially Avoidable Readmissions of Patients Discharged to Post-Acute Care: Perspectives of Hospital and Skilled Nursing Facility Staff. J Am Geriatr Soc 2016; 65:269-276. [PMID: 27981557 DOI: 10.1111/jgs.14557] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Hospital readmissions from skilled nursing facilities (SNFs) are common. Previous research has not examined how assessments of avoidable readmissions differ between hospital and SNF perspectives. OBJECTIVES To determine the percentage of readmissions from post-acute care that are considered potentially avoidable from hospital and SNF perspectives. DESIGN Prospective cohort study. SETTING One academic medical center and 23 SNFs. PARTICIPANTS We included patients from a quality improvement trial aimed at reducing hospital readmissions among patients discharged to SNFs. We included Medicare patients who were discharged to one of 23 regional SNFs between January 2013 and January 2015, and readmitted to the hospital within 30 days. MEASUREMENTS Hospital-based physicians and SNF-based staff performed structured root-cause analyses (RCA) on a sample of readmissions from a participating SNF to the index hospital. RCAs reported avoidability and factors contributing to readmissions. RESULTS The 30-day unplanned readmission rate to the index hospital from SNFs was 14.5% (262 hospital readmissions of 1,808 discharges). Of the readmissions, 120 had RCA from both the hospital and SNF. The percentage of readmissions rated as potentially avoidable was 30.0% and 13.3% according to hospital and SNF staff, respectively. Hospital and SNF ratings of potential avoidability agreed for 73.3% (88 of the 120 readmissions), but readmission factors varied between settings. Diagnostic problems and improved management of changes in conditions were the most common avoidable readmission factors by hospitals and SNFs, respectively. CONCLUSION A substantial percentage of hospital readmissions from SNFs are rated as potentially avoidable. The ratings and factors underlying avoidability differ between hospital and SNF staff. These data support the need for joint accountability and collaboration for future readmission reduction efforts between hospitals and their SNF partners.
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Affiliation(s)
- Eduard E Vasilevskis
- Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.,Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.,Geriatric Research Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville, Tennessee
| | - Joseph G Ouslander
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida
| | - Amanda S Mixon
- Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.,Geriatric Research Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville, Tennessee.,Center for Clinical Quality and Implementation Research, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Susan P Bell
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.,Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee.,Division of Geriatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - J Mary Lou Jacobsen
- Geriatric Research Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville, Tennessee.,Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Avantika A Saraf
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.,Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Daniel Markley
- Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kelly C Sponsler
- Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jill Shutes
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida
| | - Emily A Long
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sunil Kripalani
- Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.,Center for Clinical Quality and Implementation Research, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sandra F Simmons
- Geriatric Research Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville, Tennessee.,Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee.,Division of Geriatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - John F Schnelle
- Geriatric Research Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville, Tennessee.,Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee.,Division of Geriatrics, Vanderbilt University Medical Center, Nashville, Tennessee
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Saraf AA, Petersen AW, Simmons SF, Schnelle JF, Bell SP, Kripalani S, Myers AP, Mixon AS, Long EA, Jacobsen JML, Vasilevskis EE. Medications associated with geriatric syndromes and their prevalence in older hospitalized adults discharged to skilled nursing facilities. J Hosp Med 2016; 11:694-700. [PMID: 27255830 PMCID: PMC5048583 DOI: 10.1002/jhm.2614] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Revised: 04/25/2016] [Accepted: 04/28/2016] [Indexed: 11/11/2022]
Abstract
BACKGROUND More than half of the hospitalized older adults discharged to skilled nursing facilities (SNFs) have more than 3 geriatric syndromes. Pharmacotherapy may be contributing to geriatric syndromes in this population. OBJECTIVES Develop a list of medications associated with geriatric syndromes and describe their prevalence in patients discharged from acute care to SNFs. DESIGN Literature review and multidisciplinary expert panel discussion, followed by cross-sectional analysis. SETTING Academic medical center in the United States PARTICIPANTS: One hundred fifty-four hospitalized Medicare beneficiaries discharged to SNFs. MEASUREMENTS Development of a list of medications that are associated with 6 geriatric syndromes. Prevalence of the medications associated with geriatric syndromes was examined in the hospital discharge sample. RESULTS A list of 513 medications was developed as potentially contributing to 6 geriatric syndromes: cognitive impairment, delirium, falls, reduced appetite or weight loss, urinary incontinence, and depression. Medications included 18 categories. Antiepileptics were associated with all syndromes, whereas antipsychotics, antidepressants, antiparkinsonism, and opioid agonists were associated with 5 geriatric syndromes. In the prevalence sample, patients were discharged to SNFs with an overall average of 14.0 (±4.7) medications, including an average of 5.9 (±2.2) medications that could contribute to geriatric syndromes, with falls having the most associated medications at discharge at 5.5 (±2.2). CONCLUSIONS Many commonly prescribed medications are associated with geriatric syndromes. Over 40% of all medications ordered upon discharge to SNFs were associated with geriatric syndromes and could be contributing to the high prevalence of geriatric syndromes experienced by this population. Journal of Hospital Medicine 2016;11:694-700. © 2016 Society of Hospital Medicine.
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Affiliation(s)
- Avantika A Saraf
- Center for Quality Aging, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Alec W Petersen
- School of Medicine, Vanderbilt University, Nashville, Tennessee
| | - Sandra F Simmons
- Center for Quality Aging, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Division of Geriatrics, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Geriatric Research, Education and Clinical Center, VA Tennessee Valley Healthcare System, Nashville, Tennessee
| | - John F Schnelle
- Center for Quality Aging, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Division of Geriatrics, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Geriatric Research, Education and Clinical Center, VA Tennessee Valley Healthcare System, Nashville, Tennessee
| | - Susan P Bell
- Center for Quality Aging, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Division of Geriatrics, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sunil Kripalani
- Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Amy P Myers
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Amanda S Mixon
- Geriatric Research, Education and Clinical Center, VA Tennessee Valley Healthcare System, Nashville, Tennessee
- Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Emily A Long
- Center for Quality Aging, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - J Mary Lou Jacobsen
- Center for Quality Aging, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Geriatric Research, Education and Clinical Center, VA Tennessee Valley Healthcare System, Nashville, Tennessee
| | - Eduard E Vasilevskis
- Center for Quality Aging, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.
- Geriatric Research, Education and Clinical Center, VA Tennessee Valley Healthcare System, Nashville, Tennessee.
- Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.
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Mixon AS, Goggins K, Bell SP, Vasilevskis EE, Nwosu S, Schildcrout JS, Kripalani S. Preparedness for hospital discharge and prediction of readmission. J Hosp Med 2016; 11:603-9. [PMID: 26929109 PMCID: PMC5003753 DOI: 10.1002/jhm.2572] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Revised: 01/26/2016] [Accepted: 02/02/2016] [Indexed: 11/06/2022]
Abstract
BACKGROUND, OBJECTIVE Patients' self-reported preparedness for discharge has been shown to predict readmission. It is unclear what differences exist in the predictive abilities of 2 available discharge preparedness measures. To address this gap, we conducted a comparison of these measures. DESIGN, SETTING, PATIENTS Adults hospitalized for cardiovascular diagnoses were enrolled in a prospective cohort. MEASUREMENTS Two patient-reported preparedness measures assessed during postdischarge calls: the 11-item Brief Prescriptions, Ready to re-enter community, Education, Placement, Assurance of safety, Realistic expectations, Empowerment, Directed to appropriate services (B-PREPARED) and the 3-item Care Transitions Measure (CTM-3). Cox proportional hazard models analyzed the relationship between preparedness and time to first readmission or death at 30 and 90 days, adjusted for readmission risk using the administrative database-derived Length of stay, Acuity, Comorbidity, and Emergency department use (LACE) index and other covariates. RESULTS Median preparedness scores were: B-PREPARED 21 (interquartile range [IQR] 18-22) and CTM-3 77.8 (IQR 66.7-100). In individual Cox models, a 4-point increase in B-PREPARED score was associated with a 16% decrease in time to readmission or death at 30 and 90 days. A 10-point increase in CTM-3 score was not associated with readmission or death at 30 days, but was associated with a 6% decrease in readmission or death at 90 days. In models with both preparedness scores, B-PREPARED retained an association with readmission or death at both 30 and 90 days. However, neither preparedness score was as strong a predictor as the LACE index when all were included in the model predicting 30- and 90-day readmission or death. CONCLUSION The B-PREPARED score was more strongly associated with readmission or death than the more widely adopted CTM-3, but neither predicted readmission as well as the LACE index. Journal of Hospital Medicine 2016;11:603-609. © 2016 Society of Hospital Medicine.
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Affiliation(s)
- Amanda S. Mixon
- Department of Veterans Affairs, Tennessee Valley Healthcare System Geriatric Research Education and Clinical Center (GRECC), 1310 24 avenue South, Nashville, TN 37212-2637
- Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, D-3100, Medical Center North, Nashville, TN 37232-2358
- Center for Health Services Research, Vanderbilt University Medical Center, Medical Center East, Suite 6000, Nashville, Tennessee 37232-8300
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Medical Center East, Suite 6000, Nashville, Tennessee 37232-8300
| | - Kathryn Goggins
- Center for Health Services Research, Vanderbilt University Medical Center, Medical Center East, Suite 6000, Nashville, Tennessee 37232-8300
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Medical Center East, Suite 6000, Nashville, Tennessee 37232-8300
| | - Susan P. Bell
- Center for Quality Aging, Vanderbilt University Medical Center, 2525 West End Avenue, Suite 350, Nashville, TN, 37203-1425
| | - Eduard E. Vasilevskis
- Department of Veterans Affairs, Tennessee Valley Healthcare System Geriatric Research Education and Clinical Center (GRECC), 1310 24 avenue South, Nashville, TN 37212-2637
- Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, D-3100, Medical Center North, Nashville, TN 37232-2358
- Center for Health Services Research, Vanderbilt University Medical Center, Medical Center East, Suite 6000, Nashville, Tennessee 37232-8300
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Medical Center East, Suite 6000, Nashville, Tennessee 37232-8300
- Center for Quality Aging, Vanderbilt University Medical Center, 2525 West End Avenue, Suite 350, Nashville, TN, 37203-1425
| | - Samuel Nwosu
- Department of Biostatistics, Vanderbilt University Medical Center, 2525 West End, Ste. 11000 Nashville, TN 37203
| | - Jonathan S. Schildcrout
- Department of Biostatistics, Vanderbilt University Medical Center, 2525 West End, Ste. 11000 Nashville, TN 37203
| | - Sunil Kripalani
- Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, D-3100, Medical Center North, Nashville, TN 37232-2358
- Center for Health Services Research, Vanderbilt University Medical Center, Medical Center East, Suite 6000, Nashville, Tennessee 37232-8300
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Medical Center East, Suite 6000, Nashville, Tennessee 37232-8300
- Center for Quality Aging, Vanderbilt University Medical Center, 2525 West End Avenue, Suite 350, Nashville, TN, 37203-1425
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Bell SP, Schnipper JL, Goggins K, Bian A, Shintani A, Roumie CL, Dalal AK, Jacobson TA, Rask KJ, Vaccarino V, Gandhi TK, Labonville SA, Johnson D, Neal EB, Kripalani S. Effect of Pharmacist Counseling Intervention on Health Care Utilization Following Hospital Discharge: A Randomized Control Trial. J Gen Intern Med 2016; 31:470-7. [PMID: 26883526 PMCID: PMC4835388 DOI: 10.1007/s11606-016-3596-3] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Reduction in 30-day readmission rates following hospitalization for acute coronary syndrome (ACS) and acute decompensated heart failure (ADHF) is a national goal. OBJECTIVE The aim of this study was to determine the effect of a tailored, pharmacist-delivered, health literacy intervention on unplanned health care utilization, including hospital readmission or emergency room (ER) visit, following discharge. DESIGN Randomized, controlled trial with concealed allocation and blinded outcome assessors SETTING Two tertiary care academic medical centers PARTICIPANTS Adults hospitalized with a diagnosis of ACS and/or ADHF. INTERVENTION Pharmacist-assisted medication reconciliation, inpatient pharmacist counseling, low-literacy adherence aids, and individualized telephone follow-up after discharge MAIN MEASURES The primary outcome was time to first unplanned health care event, defined as hospital readmission or an ER visit within 30 days of discharge. Pre-specified analyses were conducted to evaluate the effects of the intervention by academic site, health literacy status (inadequate versus adequate), and cognition (impaired versus not impaired). Adjusted hazard ratios (aHR) and 95% confidence intervals (CI) are reported. KEY RESULTS A total of 851 participants enrolled in the study at Vanderbilt University Hospital (VUH) and Brigham and Women's Hospital (BWH). The primary analysis showed no statistically significant effect on time to first unplanned hospital readmission or ER visit among patients who received interventions compared to controls (aHR = 1.04, 95% CI 0.78-1.39). There was an interaction of treatment effect by site (p = 0.04 for interaction); VUH aHR = 0.77, 95% CI 0.51-1.15; BWH aHR = 1.44 (95% CI 0.95-2.12). The intervention reduced early unplanned health care utilization among patients with inadequate health literacy (aHR 0.41, 95% CI 0.17-1.00). There was no difference in treatment effect by patient cognition. CONCLUSION A tailored, pharmacist-delivered health literacy-sensitive intervention did not reduce post-discharge unplanned health care utilization overall. The intervention was effective among patients with inadequate health literacy, suggesting that targeted practice of pharmacist intervention in this population may be advantageous.
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Affiliation(s)
- Susan P Bell
- Vanderbilt Center for Translational and Clinical Cardiovascular Research (VTRACC), Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University, Suite 300-A 2525 West End Avenue, Nashville, TN, 37232-8300, USA.
- Center for Quality Aging, Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University, Nashville, TN, USA.
| | - Jeffrey L Schnipper
- Hospitalist Service, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Kathryn Goggins
- Center for Health Services Research, Vanderbilt University, Nashville, TN, USA
- Center for Clinical Quality and Implementation Research, Vanderbilt University, Nashville, TN, USA
| | - Aihua Bian
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Ayumi Shintani
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Christianne L Roumie
- Center for Health Services Research, Vanderbilt University, Nashville, TN, USA
- Center for Clinical Quality and Implementation Research, Vanderbilt University, Nashville, TN, USA
- Veterans Health Administration-Tennessee Valley Healthcare System, Geriatric Research Education Clinical Center, Nashville, TN, USA
| | - Anuj K Dalal
- Hospitalist Service, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Terry A Jacobson
- Hospitalist Service, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Kimberly J Rask
- Department of Epidemiology, Rollins School of Public Health, and Department of Medicine, School of Medicine, Emory University, Atlanta, GA, USA
| | - Viola Vaccarino
- Department of Epidemiology, Rollins School of Public Health, and Department of Medicine, School of Medicine, Emory University, Atlanta, GA, USA
| | | | - Stephanie A Labonville
- Department of Pharmacy Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Daniel Johnson
- Vanderbilt University, Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Erin B Neal
- Vanderbilt University, Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sunil Kripalani
- Center for Health Services Research, Vanderbilt University, Nashville, TN, USA
- Center for Clinical Quality and Implementation Research, Vanderbilt University, Nashville, TN, USA
- Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
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Bell SP, Vasilevskis EE, Saraf AA, Jacobsen JML, Kripalani S, Mixon AS, Schnelle JF, Simmons SF. Geriatric Syndromes in Hospitalized Older Adults Discharged to Skilled Nursing Facilities. J Am Geriatr Soc 2016; 64:715-22. [PMID: 27059831 DOI: 10.1111/jgs.14035] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To determine the prevalence, recognition, co-occurrence, and recent onset of geriatric syndromes in individuals transferred from the hospital to a skilled nursing facility (SNF). DESIGN Quality improvement project. SETTING Acute care academic medical center and 23 regional partner SNFs. PARTICIPANTS Medicare beneficiaries hospitalized between January 2013 and April 2014 and referred to SNFs (N = 686). MEASUREMENTS Project staff measured nine geriatric syndromes: weight loss, lack of appetite, incontinence, and pain (standardized interview); depression (Geriatric Depression Scale); delirium (Brief Confusion Assessment Method); cognitive impairment (Brief Interview for Mental Status); and falls and pressure ulcers (hospital medical record using hospital-implemented screening tools). Estimated prevalence, new-onset prevalence, and common coexisting clusters were determined. The extent to which treating physicians commonly recognized syndromes and communicated them to SNFs in hospital discharge documentation was evaluated. RESULTS Geriatric syndromes were prevalent in more than 90% of hospitalized adults referred to SNFs; 55% met criteria for three or more coexisting syndromes. The most-prevalent syndromes were falls (39%), incontinence (39%), loss of appetite (37%), and weight loss (33%). In individuals who met criteria for three or more syndromes, the most common triad clusters were nutritional syndromes (weight loss, loss of appetite), incontinence, and depression. Treating hospital physicians commonly did not recognize and document geriatric syndromes in discharge summaries, missing 33% to 95% of syndromes present according to research personnel. CONCLUSION Geriatric syndromes in hospitalized older adults transferred to SNFs are prevalent and commonly coexist, with the most frequent clusters including nutritional syndromes, depression, and incontinence. Despite the high prevalence, this clinical information is rarely communicated to SNFs on discharge.
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Affiliation(s)
- Susan P Bell
- Center for Quality Aging, Division of General Internal Medicine and Public Health, Vanderbilt University, Nashville, Tennessee.,Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University, Nashville, Tennessee
| | - Eduard E Vasilevskis
- Center for Quality Aging, Division of General Internal Medicine and Public Health, Vanderbilt University, Nashville, Tennessee.,Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Vanderbilt University, Nashville, Tennessee.,Geriatric Research Education and Clinical Center, Department of Veterans Affairs, Tennessee Valley Healthcare System, Nashville, Tennessee
| | - Avantika A Saraf
- Center for Quality Aging, Division of General Internal Medicine and Public Health, Vanderbilt University, Nashville, Tennessee.,Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University, Nashville, Tennessee
| | - J M L Jacobsen
- Center for Quality Aging, Division of General Internal Medicine and Public Health, Vanderbilt University, Nashville, Tennessee.,Geriatric Research Education and Clinical Center, Department of Veterans Affairs, Tennessee Valley Healthcare System, Nashville, Tennessee.,Center for Health Services Research, Vanderbilt University, Nashville, Tennessee
| | - Sunil Kripalani
- Center for Quality Aging, Division of General Internal Medicine and Public Health, Vanderbilt University, Nashville, Tennessee.,Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Vanderbilt University, Nashville, Tennessee.,Center for Health Services Research, Vanderbilt University, Nashville, Tennessee.,Center for Clinical Quality and Implementation Research, Vanderbilt University, Nashville, Tennessee
| | - Amanda S Mixon
- Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Vanderbilt University, Nashville, Tennessee.,Geriatric Research Education and Clinical Center, Department of Veterans Affairs, Tennessee Valley Healthcare System, Nashville, Tennessee
| | - John F Schnelle
- Center for Quality Aging, Division of General Internal Medicine and Public Health, Vanderbilt University, Nashville, Tennessee.,Geriatric Research Education and Clinical Center, Department of Veterans Affairs, Tennessee Valley Healthcare System, Nashville, Tennessee.,Division of Geriatrics, Department of Medicine, Vanderbilt University, Nashville, Tennessee
| | - Sandra F Simmons
- Center for Quality Aging, Division of General Internal Medicine and Public Health, Vanderbilt University, Nashville, Tennessee.,Geriatric Research Education and Clinical Center, Department of Veterans Affairs, Tennessee Valley Healthcare System, Nashville, Tennessee.,Division of Geriatrics, Department of Medicine, Vanderbilt University, Nashville, Tennessee
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Bell SP, Orr NM, Dodson JA, Rich MW, Wenger NK, Blum K, Harold JG, Tinetti ME, Maurer MS, Forman DE. What to Expect From the Evolving Field of Geriatric Cardiology. J Am Coll Cardiol 2015; 66:1286-1299. [PMID: 26361161 DOI: 10.1016/j.jacc.2015.07.048] [Citation(s) in RCA: 85] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Revised: 07/24/2015] [Accepted: 07/26/2015] [Indexed: 11/20/2022]
Abstract
The population of older adults is expanding rapidly, and aging predisposes to cardiovascular disease. The principle of patient-centered care must respond to the preponderance of cardiac disease that now occurs in combination with the complexities of old age. Geriatric cardiology melds cardiovascular perspectives with multimorbidity, polypharmacy, frailty, cognitive decline, and other clinical, social, financial, and psychological dimensions of aging. Although some assume that a cardiologist may instinctively cultivate some of these skills over the course of a career, we assert that the volume and complexity of older cardiovascular patients in contemporary practice warrants a more direct approach to achieve suitable training and a more reliable process of care. We present a rationale and vision for geriatric cardiology as a melding of primary cardiovascular and geriatrics skills, thereby infusing cardiology practice with expanded proficiencies in diagnosis, risks, care coordination, communications, end-of-life, and other competences required to best manage older cardiovascular patients.
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Affiliation(s)
- Susan P Bell
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee; Center for Quality Aging, Division of Geriatric Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Nicole M Orr
- Division of Cardiology and the Cardiovascular Center, Tufts Medical Center, Boston, Massachusetts
| | - John A Dodson
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University School of Medicine, New York, New York
| | - Michael W Rich
- Division of Cardiology, Washington University School of Medicine, St. Louis, Missouri
| | - Nanette K Wenger
- Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia
| | - Kay Blum
- Geriatric Cardiology Section, American College of Cardiology, Washington, DC
| | - John Gordon Harold
- Cedars-Sinai Heart Institute and David Geffen School of Medicine, University of California, Los Angeles, California
| | - Mary E Tinetti
- Departments of Internal Medicine and Public Health and Epidemiology, Yale School of Medicine, New Haven, Connecticut
| | - Mathew S Maurer
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Daniel E Forman
- Geriatric Cardiology Section, Department of Medicine, University of Pittsburgh Medical Center, and Research, Education, and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.
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Bell SP, Schnelle J, Nwosu SK, Schildcrout J, Goggins K, Cawthon C, Mixon AS, Vasilevskis EE, Kripalani S. Development of a multivariable model to predict vulnerability in older American patients hospitalised with cardiovascular disease. BMJ Open 2015; 5:e008122. [PMID: 26316650 PMCID: PMC4554894 DOI: 10.1136/bmjopen-2015-008122] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVES To identify vulnerable cardiovascular patients in the hospital using a self-reported function-based screening tool. PARTICIPANTS Prospective observational cohort study of 445 individuals aged ≥ 65 years admitted to a university medical centre hospital within the USA with acute coronary syndrome and/or decompensated heart failure. METHODS Participants completed an inperson interview during hospitalisation, which included vulnerable functional status using the Vulnerable Elders Survey (VES-13), sociodemographic, healthcare utilisation practices and clinical patient-specific measures. A multivariable proportional odds logistic regression model examined associations between VES-13 and prior healthcare utilisation, as well as other coincident medical and psychosocial risk factors for poor outcomes in cardiovascular disease. RESULTS Vulnerability was highly prevalent (54%) and associated with a higher number of clinic visits, emergency room visits and hospitalisations (all p<0.001). A multivariable analysis demonstrating a 1-point increase in VES-13 (vulnerability) was independently associated with being female (OR 1.55, p=0.030), diagnosis of heart failure (OR 3.11, p<0.001), prior hospitalisations (OR 1.30, p<0.001), low social support (OR 1.42, p=0.007) and depression (p<0.001). A lower VES-13 score (lower vulnerability) was associated with increased health literacy (OR 0.70, p=0.002). CONCLUSIONS Vulnerability to functional decline is highly prevalent in hospitalised older cardiovascular patients and was associated with patient risk factors for adverse outcomes and an increased use of healthcare services.
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Affiliation(s)
- Susan P Bell
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University, Nashville, Tennessee, USA
- Division of General Internal Medicine and Public Health, Department of Medicine, Center for Quality Aging, Vanderbilt University, Nashville, Tennessee, USA
| | - John Schnelle
- Division of General Internal Medicine and Public Health, Department of Medicine, Center for Quality Aging, Vanderbilt University, Nashville, Tennessee, USA
| | - Samuel K Nwosu
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jonathan Schildcrout
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kathryn Goggins
- Center for Clinical Quality and Implementation Research, Nashville, Tennessee, USA
| | - Courtney Cawthon
- Center for Health Services Research, Vanderbilt University, Nashville, Tennessee, USA
| | - Amanda S Mixon
- Center for Clinical Quality and Implementation Research, Nashville, Tennessee, USA
- Department of Veterans Affairs, Tennessee Valley Healthcare System—Geriatric Research Education and Clinical Center (GRECC), Nashville, Tennessee, USA
- Division of General Internal Medicine and Public Health, Department of Medicine, Section of Hospital Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - Eduard E Vasilevskis
- Center for Clinical Quality and Implementation Research, Nashville, Tennessee, USA
- Department of Veterans Affairs, Tennessee Valley Healthcare System—Geriatric Research Education and Clinical Center (GRECC), Nashville, Tennessee, USA
- Division of General Internal Medicine and Public Health, Department of Medicine, Section of Hospital Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - Sunil Kripalani
- Center for Clinical Quality and Implementation Research, Nashville, Tennessee, USA
- Center for Health Services Research, Vanderbilt University, Nashville, Tennessee, USA
- Division of General Internal Medicine and Public Health, Department of Medicine, Section of Hospital Medicine, Vanderbilt University, Nashville, Tennessee, USA
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Hohman TJ, Bell SP, Jefferson AL. The role of vascular endothelial growth factor in neurodegeneration and cognitive decline: exploring interactions with biomarkers of Alzheimer disease. JAMA Neurol 2015; 72:520-9. [PMID: 25751166 DOI: 10.1001/jamaneurol.2014.4761] [Citation(s) in RCA: 112] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
IMPORTANCE A subset of older adults present post mortem with Alzheimer disease (AD) pathologic features but without any significant clinical manifestation of dementia. Vascular endothelial growth factor (VEGF) has been implicated in staving off AD-related neurodegeneration. OBJECTIVE To evaluate whether VEGF levels are associated with brain aging outcomes (hippocampal volume and cognition) and to further evaluate whether VEGF modifies relations between AD biomarkers and brain aging outcomes. DESIGN, SETTING, AND PARTICIPANTS Biomarker analysis using neuroimaging and neuropsychological outcomes from the Alzheimer's Disease Neuroimaging Initiative. This prospective longitudinal study across North America included individuals with normal cognition (n = 90), mild cognitive impairment (n = 130), and AD (n = 59) and began in October 2004, with follow-up ongoing. MAIN OUTCOMES AND MEASURES Cerebrospinal fluid VEGF was cross-sectionally related to brain aging outcomes (hippocampal volume, episodic memory, and executive function) using a general linear model and longitudinally using mixed-effects regression. Alzheimer disease biomarker (cerebrospinal fluid β-amyloid 42 and total tau)-by-VEGF interactions evaluated the effect of VEGF on brain aging outcomes in the presence of enhanced AD biomarkers. RESULTS Vascular endothelial growth factor was associated with baseline hippocampal volume (t277 = 2.62; P = .009), longitudinal hippocampal atrophy (t858 = 2.48; P = .01), and longitudinal decline in memory (t1629 = 4.09; P < .001) and executive function (t1616 = 3.00; P = .003). Vascular endothelial growth factor interacted with tau in predicting longitudinal hippocampal atrophy (t845 = 4.17; P < .001), memory decline (t1610 = 2.49; P = .01), and executive function decline (t1597 = 3.71; P < .001). Vascular endothelial growth factor interacted with β-amyloid 42 in predicting longitudinal memory decline (t1618 = -2.53; P = .01). CONCLUSIONS AND RELEVANCE Elevated cerebrospinal fluid VEGF was associated with more optimal brain aging in vivo. The neuroprotective effect appeared strongest in the presence of enhanced AD biomarkers, suggesting that VEGF may be particularly beneficial in individuals showing early hallmarks of the AD cascade. Future work should evaluate the interaction between VEGF expression in vitro and pathologic burden to address potential mechanisms.
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Affiliation(s)
- Timothy J Hohman
- Vanderbilt Memory & Alzheimer's Center, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Susan P Bell
- Vanderbilt Memory & Alzheimer's Center, Vanderbilt University School of Medicine, Nashville, Tennessee2Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee3Center for Quality Aging, Di
| | - Angela L Jefferson
- Vanderbilt Memory & Alzheimer's Center, Vanderbilt University School of Medicine, Nashville, Tennessee
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Leak C, Goggins K, Schildcrout JS, Theobald C, Donato KM, Bell SP, Schnelle J, Kripalani S. Effect of Health Literacy on Research Follow-Up. J Health Commun 2015; 20 Suppl 2:83-91. [PMID: 26513035 PMCID: PMC4706551 DOI: 10.1080/10810730.2015.1058442] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Previous research has not examined the effect of health literacy on research subjects' completion of scheduled research follow-up. This article evaluates patient factors associated with incomplete research follow-up at three time points after enrollment in a large, hospital-based prospective cohort study. Predictor variables included health literacy, age, race, gender, education, employment status, difficulty paying bills, hospital diagnosis, length of stay, self-reported global health status, depression, perceived health competence, medication adherence, and health care system distrust. In a sample of 2,042 patients, multivariable models demonstrated that lower health literacy and younger age were significantly associated with a lower likelihood of completing research follow-up interviews at 2-3 days, 30 days, and 90 days after hospital discharge. In addition, patients who had less education, were currently employed, and had moderate financial stress were less likely to complete 90-day follow-up. This study is the first to demonstrate that lower health literacy is a significant predictor of incomplete research follow-up.
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Affiliation(s)
- Cardella Leak
- Institute for Medicine and Public Health, Vanderbilt University Medical Center
| | - Kathryn Goggins
- Center for Health Services Research, Vanderbilt University Medical Center
- Center for Effective Health Communication, Vanderbilt University Medical Center
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center
| | - Jonathan S. Schildcrout
- Department of Biostatistics, Vanderbilt University Medical Center
- Department of Anesthesiology, Vanderbilt University Medical Center
| | - Cecelia Theobald
- Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center
| | | | - Susan P. Bell
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center
- Center for Quality Aging, Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center
| | - John Schnelle
- Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center
- Center for Quality Aging, Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center
- Geriatric Research, Education, and Clinical Center, Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee
| | - Sunil Kripalani
- Center for Health Services Research, Vanderbilt University Medical Center
- Center for Effective Health Communication, Vanderbilt University Medical Center
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center
- Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center
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Lawson MA, Bell SP, Adkisson DW, Wang L, Ooi H, Sawyer DB, Kronenberg MW. High reproducibility of adenosine stress cardiac MR myocardial perfusion imaging in patients with non-ischaemic dilated cardiomyopathy. BMJ Open 2014; 4:e005984. [PMID: 25515841 PMCID: PMC4275661 DOI: 10.1136/bmjopen-2014-005984] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To evaluate the reproducibility of first-pass contrast-enhanced cardiac MR (CMR) myocardial perfusion imaging in patients with non-ischaemic dilated cardiomyopathy (NIDCM). DESIGN Prospective observational study. SETTING Single centre, tertiary care hospital. PARTICIPANTS 6 outpatient participants with NIDCM. OUTCOME Reproducibility of semiquantitative myocardial perfusion analysis by CMR. METHOD 6 patients with NIDCM were studied twice using first-pass of contrast transit through the left ventricular (LV) myocardium with a saturation-recovery gradient echo sequence at rest and during adenosine-induced hyperaemia. The anterior wall was divided into endocardial (Endo) and epicardial (Epi) segments. The Myocardial Perfusion Index (MPI) was calculated as the myocardial signal augmentation rate normalised to the LV cavity rate. The Myocardial Perfusion Reserve Index (MPRI) was calculated as hyperaemic/resting MPI. RESULTS Between study 1 and 2, median MPI was similar for resting Endo (0.076 vs 0.077), hyperaemic Endo (0.143 vs 0.143), resting Epi (0.073 vs 0.074), and hyperaemic Epi (0.135 vs 0.134). Median MPRI was similar for Endo (1.84 vs 1.87) and Epi (1.90 vs 2.00). Combining Endo and Epi MPI (N=12), there was excellent agreement between Study 1 and 2 for resting MPI (r=0.998, intraclass correlation coefficient (ICC) 0.998, coefficients of variation (CoV) 1.4%), hyperaemic MPI (r=0.979, ICC 0.963, CoV 3.3%) and MPRI (r=0.989, ICC 0.94, CoV 3.8%). CONCLUSIONS Resting and hyperaemic myocardial perfusion using a normalised upslope analysis during adenosine CMR is a highly reproducible technique in patients with NIDCM. TRIAL REGISTRATION NUMBER Clinical Trials.Gov ID NCT00574119.
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Affiliation(s)
- Mark A Lawson
- Division of Cardiovascular Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Susan P Bell
- Division of Cardiovascular Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Douglas W Adkisson
- Division of Cardiovascular Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Li Wang
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Henry Ooi
- Division of Cardiovascular Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
- Cardiology Section, Department of Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee, USA
| | - Douglas B Sawyer
- Division of Cardiovascular Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Marvin W Kronenberg
- Division of Cardiovascular Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
- Cardiology Section, Department of Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee, USA
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Abstract
Cardiovascular disease (CVD) is the leading cause of mortality in older adults, however, in the elderly accurate stratification of CVD risk to guide management decisions is challenging due to the heterogeneity of the population. Conventional assessment of CVD and therapeutic risk is based on extrapolation of guidelines developed from evidence demonstrated in younger individuals and fails to weight the increased burden of complications and multimorbidity. Using a comprehensive geriatric based assessment of older adults with CVD that includes an estimation of complexity of multimorbidity as well as traditional risk assessment provides a patient centered approach that allows for management decisions congruent with patient preferences. This review examines the complexity of risk stratification in adults over 80, assessment methods to augment current tools and the basis of management decisions to optimize patient and family centered goals.
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Affiliation(s)
- Susan P Bell
- Division of Cardiovascular Medicine and the Center for Quality Aging, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA.
| | - Avantika Saraf
- Division of Cardiovascular Medicine and the Center for Quality Aging, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
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Bell SP, Adkisson DW, Lawson MA, Wang L, Ooi H, Sawyer DB, Kronenberg MW. Antifailure therapy including spironolactone improves left ventricular energy supply-demand relations in nonischemic dilated cardiomyopathy. J Am Heart Assoc 2014; 3:e000883. [PMID: 25164945 PMCID: PMC4310370 DOI: 10.1161/jaha.114.000883] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2014] [Accepted: 08/04/2014] [Indexed: 12/26/2022]
Abstract
BACKGROUND Left ventricular (LV) energy supply-demand imbalance is postulated to cause "energy starvation" and contribute to heart failure (HF) in nonischemic dilated cardiomyopathy (NIDCM). Using cardiac magnetic resonance (CMR) and [(11)C] acetate positron emission tomography (PET), we evaluated LV perfusion and oxidative metabolism in NIDCM and the effects of spironolactone on LV supply-demand relations. METHODS AND RESULTS Twelve patients with NIDCM underwent CMR and PET at baseline and after ≥6 months of spironolactone therapy added to a standard HF regimen. The myocardial perfusion reserve index (MPRI) was calculated after gadolinium injection during adenosine, as compared to rest. The monoexponential clearance rate of [(11)C] acetate (kmono) was used to calculate the work metabolic index (WMI), an index of LV mechanical efficiency, and kmono/RPP (rate-pressure product), an index of energy supply/demand. At baseline, the subendocardium was hypoperfused versus the subepicardium (median MPRI, 1.63 vs. 1.80; P<0.001), but improved to 1.80 (P<0.001) after spironolactone. The WMI increased (P=0.001), as did kmono/RPP (P=0.003). These improvements were associated with reverse remodeling, increased LV ejection fraction, and decreases in LV mass and systolic wall stress (all P<0.002). CONCLUSIONS NIDCM is associated with subendocardial hypoperfusion and impaired myocardial oxidative metabolism, consistent with energy starvation. Antifailure therapy improves parameters of energy starvation and is associated with augmented LV performance. CLINICAL TRIAL REGISTRATION URL http://www.clinicaltrials.gov/ Unique identifier: ID NCT00574119.
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Affiliation(s)
- Susan P. Bell
- Division of Cardiovascular Medicine, Vanderbilt University School of Medicine, VA Tennessee Valley Healthcare System, Nashville, TN (S.P.B., D.W.A., M.A.L., H.O., D.B.S., M.W.K.)
| | - Douglas W. Adkisson
- Division of Cardiovascular Medicine, Vanderbilt University School of Medicine, VA Tennessee Valley Healthcare System, Nashville, TN (S.P.B., D.W.A., M.A.L., H.O., D.B.S., M.W.K.)
| | - Mark A. Lawson
- Division of Cardiovascular Medicine, Vanderbilt University School of Medicine, VA Tennessee Valley Healthcare System, Nashville, TN (S.P.B., D.W.A., M.A.L., H.O., D.B.S., M.W.K.)
| | - Li Wang
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN (L.W.)
| | - Henry Ooi
- Division of Cardiovascular Medicine, Vanderbilt University School of Medicine, VA Tennessee Valley Healthcare System, Nashville, TN (S.P.B., D.W.A., M.A.L., H.O., D.B.S., M.W.K.)
- Cardiology Section, VA Tennessee Valley Healthcare System, Nashville, TN (H.O., M.W.K.)
| | - Douglas B. Sawyer
- Division of Cardiovascular Medicine, Vanderbilt University School of Medicine, VA Tennessee Valley Healthcare System, Nashville, TN (S.P.B., D.W.A., M.A.L., H.O., D.B.S., M.W.K.)
| | - Marvin W. Kronenberg
- Division of Cardiovascular Medicine, Vanderbilt University School of Medicine, VA Tennessee Valley Healthcare System, Nashville, TN (S.P.B., D.W.A., M.A.L., H.O., D.B.S., M.W.K.)
- Cardiology Section, VA Tennessee Valley Healthcare System, Nashville, TN (H.O., M.W.K.)
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Meyers AG, Salanitro A, Wallston KA, Cawthon C, Vasilevskis EE, Goggins KM, Davis CM, Rothman RL, Castel LD, Donato KM, Schnelle JF, Bell SP, Schildcrout JS, Osborn CY, Harrell FE, Kripalani S. Determinants of health after hospital discharge: rationale and design of the Vanderbilt Inpatient Cohort Study (VICS). BMC Health Serv Res 2014; 14:10. [PMID: 24397292 PMCID: PMC3893361 DOI: 10.1186/1472-6963-14-10] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2013] [Accepted: 01/03/2014] [Indexed: 11/10/2022] Open
Abstract
Background The period following hospital discharge is a vulnerable time for patients when errors and poorly coordinated care are common. Suboptimal care transitions for patients admitted with cardiovascular conditions can contribute to readmission and other adverse health outcomes. Little research has examined the role of health literacy and other social determinants of health in predicting post-discharge outcomes. Methods The Vanderbilt Inpatient Cohort Study (VICS), funded by the National Institutes of Health, is a prospective longitudinal study of 3,000 patients hospitalized with acute coronary syndromes or acute decompensated heart failure. Enrollment began in October 2011 and is planned through October 2015. During hospitalization, a set of validated demographic, cognitive, psychological, social, behavioral, and functional measures are administered, and health status and comorbidities are assessed. Patients are interviewed by phone during the first week after discharge to assess the quality of hospital discharge, communication, and initial medication management. At approximately 30 and 90 days post-discharge, interviewers collect additional data on medication adherence, social support, functional status, quality of life, and health care utilization. Mortality will be determined with up to 3.5 years follow-up. Statistical models will examine hypothesized relationships of health literacy and other social determinants on medication management, functional status, quality of life, utilization, and mortality. In this paper, we describe recruitment, eligibility, follow-up, data collection, and analysis plans for VICS, as well as characteristics of the accruing patient cohort. Discussion This research will enhance understanding of how health literacy and other patient factors affect the quality of care transitions and outcomes after hospitalization. Findings will help inform the design of interventions to improve care transitions and post-discharge outcomes.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Sunil Kripalani
- Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University, 1215 21st Ave S, Suite 6000 Medical Center East, Nashville 37232, TN, USA.
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Gupta C, Bell SP, Schildcrout JS, Fletcher S, Goggins KM, Kripalani S. Predictors of health care system and physician distrust in hospitalized cardiac patients. J Health Commun 2014; 19 Suppl 2:44-60. [PMID: 25315583 PMCID: PMC4318514 DOI: 10.1080/10810730.2014.934936] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Trusting relationships among patients, physicians, and the health care system is important in encouraging self-care behaviors in cardiovascular patients. This study aimed to assess the prevalence of health care system and physician distrust in this population, compare the 2 forms of distrust, and describe the demographic, socioeconomic, and psychosocial predictors of high distrust. A total of 1,232 hospitalized adults with acute coronary syndrome or heart failure were enrolled in a prospective, observational study assessing health care system distrust and physician distrust. High health care system distrust (35%) was observed across the population, with lower levels of interpersonal physician distrust (16%). In a multivariate analysis, poor social support and coping skills were strong predictors of both health care system (p=.026, p=.003) and physician distrust (p<.001, p=.006). Individuals with low or marginal health literacy had a higher likelihood of physician distrust (p<.001), but no relation was found between health literacy and health care system distrust. In conclusion, distrust is common among acutely ill cardiac patients. Those with low social support and low coping skills are more distrusting of physicians and the health care system.
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Affiliation(s)
- Charu Gupta
- a Division of Cardiovascular Medicine, Department of Medicine , Vanderbilt University School of Medicine , Nashville , Tennessee , USA
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