Frailty, cognitive impairment and anticoagulation among older adults with non-valvular atrial fibrillation

BACKGROUND/OBJECTIVES Oral anticoagulation (OAC) is challenging in older patients with nonvalvular atrial fibrillation (NVAF) who are often frail and have cognitive impairment. We examined the characteristics of older NVAF patients associated with higher odds of physical and cognitive impairments. We also examined if these high-risk patients have different OAC prescribing patterns and their satisfaction with treatment because it may impact optimal management of their NVAF. METHODS The patients in the Systematic Assessment of Geriatric Elements in Atrial Fibrillation (SAGE-AF study cohort 2016–2018) had NVAF, were aged 65 and older, and eligible for the receipt of OAC. Measures included frailty (Fried Frailty scale), cognitive impairment (Montreal Cognitive Assessment Battery), OAC prescribing and type (direct oral anticoagulant [DOAC] or vitamin K antagonist [VKA]), depressive symptoms (Patient Health Questionnaire-9), bleeding, stroke risk, and treatment benefit (Anti-Clot Treatment Scale). RESULTS Patients (n = 1,244) were 49% female, aged 76 (standard deviation = 7) years. A total of 14% were frail, and 42% had cognitive impairment. Frailty and cognitive impairment co-occurred in 9%. Odds of having both impairments versus none were higher with depression (odds ratio [OR] = 4.62; 95% confidence interval [CI] = 2.59–8.26), older age (OR = 1.56; 95% CI = 1.29–1.88), lower education (OR = 3.81; 95%CI = 2.13–6.81), race/ethnicity other than non-Hispanic White (OR = 7.94; 95% CI = 4.34–14.55), bleeding risk (OR = 1.43; 95% CI = 1.12–1.81), and stroke risk (OR = 1.35; 95% CI = 1.13–1.62). OAC prescribing was not associated with CI and frailty status. Among patients taking OACs (85%), those with both impairments were more likely to take DOAC than VKA (OR = 1.69; 95% CI = 1.01–2.80). Having both impairments (OR = 1.87; 95% CI = 1.08–3.27) or cognitive impairment (OR = 1.56; 95% CI = 1.09–2.24) was associated with higher odds of reporting lower treatment benefit. CONCLUSION In a large cohort of older NVAF patients, half were frail or cognitively impaired, and 9% had both impairments. We highlight the characteristics of patients who may benefit from cognitive and physical function screenings to maximize treatment and enhance prognosis. Finally, the co-occurrence of impairment was associated with low perceived benefit of treatment that may impede optimal management

Psychosocial and cognitive multimorbidity and health-related quality of life and symptom burden in older adults with atrial fibrillation: The systematic assessment of geriatric elements in atrial fibrillation (SAGE-AF) cohort study

BACKGROUND: Depression, anxiety, and cognitive impairments occur in up to 40 % of adults with AF and are associated with poorer health-related quality of life (HRQoL) and higher symptom burden. However, it is unknown how often these impairments co-occur, or multimorbidity, and how multimorbidity effects HRQoL and symptom burden. METHODS: Patients with AF age \u3e /=65 years with a CHA2DS2VASC risk score \u3e /= 2 and eligible for oral anticoagulation therapy were recruited from five clinics in a prospective cohort study. Participants completed validated measures of depression (PHQ9) and anxiety (GAD7), cognitive impairment (MoCA), and HRQOL and AF symptom burden (AFEQT). Multinomial logistic regression was used. RESULTS: Participants (N = 1244, 49 % female) were on average 76 +/- 7 years; 86 % were non-Hispanic white. Approximately 35 % of participants had 1 impairment, 17 % had 2 impairments and 8% had 3 impairments; 39 % had none of the 3 impairments examined. Compared to participants with no impairments, patients with 1, 2 and 3 impairments had higher odds of poor HRQoL (adjusted OR [AOR] = 1.77, 95 % CI 1.21, 2.60; AOR = 6.64, 95 % CI 4.43, 9.96; and AOR = 7.50, 95 % CI 4.40, 12.77, respectively) and those with 2 and 3 impairments had higher odds of high symptom burden (AOR = 3.69 95 % CI 2.22, 6.13; and AOR = 5.41 95 % CI 2.85, 10.26). CONCLUSIONS: Psychosocial/cognitive multimorbidity is common among older adults with AF and is associated with poor HRQoL and high symptom burden. Clinicians might consider incorporating psychosocial and cognitive screens into routine care as this may identify a high-risk population

Factors Associated With Patient Engagement in Shared Decision-Making for Stroke Prevention Among Older Adults with Atrial Fibrillation

Objective: To examine the extent of, and factors associated with, patient engagement in shared decision-making (SDM) for stroke prevention among patients with atrial fibrillation (AF). Methods: We used data from the Systematic Assessment of Geriatric Elements-Atrial Fibrillation study which includes older ( \u3e /=65 years) patients with AF and a CHA2DS2-VASc \u3e /=2. Participants reported engagement in SDM by answering whether they actively participated in choosing to take an oral anticoagulant (OAC) for their condition. Multiple logistic regression was used to assess associations between sociodemographic, clinical, geriatric, and psychosocial factors and patient engagement in SDM. Results: A total of 807 participants (mean age 75 years; 48% female) on an OAC were studied. Of these, 61% engaged in SDM. Older participants ( \u3e /=80 years) and those cognitively impaired were less likely to engage in SDM, while those very knowledgeable of their AF associated stroke risk were more likely to do so than respective comparison groups. Conclusions: A considerable proportion of older adults with AF did not engage in SDM for stroke prevention with older patients and those cognitively impaired less likely to do so. Clinicians should identify patients who are less likely to engage in SDM, promote patient engagement, and foster better patient-provider communication which may enhance long-term patient outcomes

Multimorbidity, physical frailty, and self-rated health in older patients with atrial fibrillation

BACKGROUND: Holistic care models emphasize management of comorbid conditions to improve patient-reported outcomes in treatment of atrial fibrillation (AF). We investigated relations between multimorbidity, physical frailty, and self-rated health (SRH) among older adults with AF. METHODS: Patients (n = 1235) with AF aged 65 years and older were recruited from five medical centers in Massachusetts and Georgia between 2015 and 2018. Ten previously diagnosed cardiometabolic and 8 non-cardiometabolic conditions were assessed from medical records. Physical Frailty was assessed with the Cardiovascular Health Study frailty scale. SRH was categorized as either excellent/very good , good , and fair/poor . Separate multivariable ordinal logistic models were used to examine the associations between multimorbidity and SRH, physical frailty and SRH, and multimorbidity and physical frailty. RESULTS: Overall, 16% of participants rated their health as fair/poor and 14% were frail. Hypertension (90%), dyslipidemia (80%), and heart failure (37%) were the most prevalent cardiometabolic conditions. Arthritis (51%), anemia (31%), and cancer (30%), the most common non-cardiometabolic diseases. After multivariable adjustment, patients with higher multimorbidity were more likely to report poorer health status (Odds Ratio (OR): 2.15 [95% CI: 1.53-3.03], \u3e /= 8 vs 1-4; OR: 1.37 [95% CI: 1.02-1.83], 5-7 vs 1-4), as did those with more prevalent cardiometabolic and non-cardiometabolic conditions. Patients who were pre-frail (OR: 1.73 [95% CI: 1.30-2.30]) or frail (OR: 6.81 [95% CI: 4.34-10.68]) reported poorer health status. Higher multimorbidity was associated with worse frailty status. CONCLUSIONS: Multimorbidity and physical frailty were common and related to SRH. Our findings suggest that holistic management approaches may influence SRH among older patients with AF

A cross-sectional analysis of racial differences in accelerated aging and cognitive function among patients with atrial fibrillation: The SAGE-AF study: Forrester, Accelerated aging and cognitive function

Background: Non-Whites are more likely to suffer from cognitive impairment and complications of atrial fibrillation (AF) than Whites, though Whites are more likely to be diagnosed with AF. We examined whether non-Whites with AF are biologically older than Whites with AF and whether accelerated biological aging is associated with cognitive functioning. Methods: We used baseline data from the ongoing Systematic Assessment of Geriatric Elements in Atrial Fibrillation prospective cohort study, collected 2016-2020 across ambulatory care practices in Massachusetts and Georgia. Of 1244 enrolled, 974 participants with full biological data were included in the present analysis. Accelerated aging (AccA) was calculated based on a combination of biomarkers associated with age and physiological wear and tear. Findings: The main outcome was score on Montreal Cognitive Assessment (MoCA). Non-Whites had 2.9 years more AccA than Whites and higher AccA was associated with a lower MoCA score among both Whites (-0.06, 95% CI: -0.10, -0.03) and non-Whites (-0.14, 95% CI: -0.27, 0.02). This association was significantly greater among non-whites (-0.11, 95% CI: -0.20, -0.01). Interpretation: Non-White AF patients are functionally older than their White counterparts and experience a stronger deleterious association between AccA and cognition. These findings underscore the importance of taking functional age into account when treating patients with AF, particularly non-White patients, to enhance treatment and improve AF outcomes

Differences in Perceived and Predicted Bleeding Risk in Older Adults With Atrial Fibrillation: The SAGE-AF Study

Background Little research has evaluated patient bleeding risk perceptions in comparison with calculated bleeding risk among oral anticoagulant users with atrial fibrillation. Our objective was to investigate underestimation of bleeding risk and to describe the characteristics and patient-reported outcomes associated with underestimation of bleeding risk. Methods and Results In the SAGE-AF (Systematic Assessment of Geriatric Elements in Atrial Fibrillation) study, a prospective cohort study of patients \u3e /=65 years with atrial fibrillation, a CHA2DS2-VASc risk score \u3e /=2 and who were on oral anticoagulant therapy, we compared patients\u27 self-reported bleeding risk with their predicted bleeding risk from their HAS-BLED score. Among the 754 participants (mean age 74.8 years, 48.3% women), 68.0% underestimated their bleeding risk. Participants who were Asian or Pacific Islander, Black, Native American or Alaskan Native, Mixed Race or Hispanic (non-White) (adjusted OR [AOR], 0.45; 95% CI, 0.24-0.82) and women (AOR, 0.62; 95% CI, 0.40-0.95) had significantly lower odds of underestimating their bleeding risk than respective comparison groups. Participants with a history of bleeding (AOR, 3.07; 95% CI, 1.73-5.44) and prior hypertension (AOR, 4.33; 95% CI, 2.43-7.72), stroke (AOR, 5.18; 95% CI, 1.87-14.40), or renal disease (AOR, 5.05; 95% CI, 2.98-8.57) had significantly higher odds of underestimating their bleeding risk. Conclusions We found that more than two-thirds of patients with atrial fibrillation on oral anticoagulant therapy underestimated their bleeding risk and that participants with a history of bleeding and several comorbid conditions were more likely to underestimate their bleeding risk whereas non-Whites and women were less likely to underestimate their bleeding risk. Clinicians should ensure that patients prescribed oral anticoagulant therapy have a thorough understanding of bleeding risk

Temporal Trends and Patient Characteristics Associated with 30-Day Hospital Readmission Rates after a First Acute Myocardial Infarction

BACKGROUND: Limited data exist about relatively recent trends in the magnitude and characteristics of patients who are re-hospitalized after hospital admission for an acute myocardial infarction. This study examined trends in the frequency and sociodemographic and clinical characteristics of patients readmitted to the hospital within 30 days after an initial acute myocardial infarction. METHODS: We reviewed the medical records of 3116 individuals who were hospitalized for a validated first acute myocardial infarction in 6 study periods between 2003 and 2015 at the 3 major medical centers in central Massachusetts. RESULTS: The median age of our population was 67 years, and 42% were women. The risk of being readmitted to the hospital within 30 days after an initial acute myocardial infarction increased slightly during the most recent study years after controlling for potentially confounding factors. Overall, older adults and patients with previously diagnosed atrial fibrillation, heart failure, diabetes, chronic kidney disease, stroke, and peripheral vascular disease were at higher risk for being readmitted to the hospital than respective comparison groups. For those hospitalized in the most recent study years of 2011/2015, a higher risk of rehospitalization was associated with a previous diagnosis of chronic kidney disease, peripheral vascular disease, the presence of 3 or more chronic conditions, and having developed atrial fibrillation or heart failure during the patient\u27s hospitalization for a first acute myocardial infarction. CONCLUSIONS: We identified several groups at higher risk for hospital readmission in whom enhanced surveillance efforts as well as tailored educational and treatment approaches remain needed

Self-reported risk of stroke and factors associated with underestimation of stroke risk among older adults with atrial fibrillation: the SAGE-AF study

Background: Though engaging patients with atrial fibrillation (AF) in understanding their stroke risk is encouraged by guidelines, little is known regarding AF patients\u27 perceived stroke risk or its relationship with oral anticoagulation (OAC) use. We aim to identify factors associated with underestimation of stroke risk among older patients with AF and relate this to OAC use. Methods: Data are from the ongoing SAGE (Systematic Assessment of Geriatric Elements)-AF study, which included older patients ( \u3e 65 years) with non-valvular AF and a CHA2DS2-VASc score of \u3e /= 2. Participants reported their perceived risk of having a stroke without OAC. We compared the perceived risk to CHA2DS2-VASc predicted stroke risk and classified participants as over or under estimators, and identified factors associated with underestimation of risk using multiple logistic regression. Results: The average CHA2DS2-VASc score of 915 participants (average age: 75 years, 47% female, 86% white) was 4.3 +/- 1.6, 43% of participants had discordant predicted and self-reported stroke risks. Among the 376 participants at highest risk (CHA2DS2-VASc score \u3e /= 5), 46% of participants underestimated their risk. Older participants ( \u3e /= 85 years) were more likely and OAC treated patients less likely to underestimate their risk of developing a future stroke than respective comparison groups. Conclusions: A significant proportion of study participants misperceived their stroke risk, mostly by overestimating. Almost half of participants at high risk of stroke underestimated their risk, with older patients more likely to do so. Patients on OAC were less likely to underestimate their risk, suggesting that successful efforts to educate patients about their stroke risk may influence treatment choices

Impact of comorbid conditions on disease-specific quality of life in older men and women with atrial fibrillation

BACKGROUND: Older persons with atrial fibrillation (AF) experience significant impairment in quality of life (QoL), which may be partly attributable to their comorbid diseases. A greater understanding of the impact of comorbidities on QoL could optimize patient-centered care among older persons with AF. OBJECTIVE: To assess impairment in disease-specific QoL due to comorbid conditions in older adults with AF. METHODS: Patients aged \u3e /= 65 years diagnosed with AF were recruited from five medical centers in Massachusetts and Georgia between 2015 and 2018. At 1 year of follow-up, the Quality of Life Disease Impact Scale-for Multiple Chronic Conditions was used to provide standardized assessment of patient self-reported impairment in QoL attributable to 34 comorbid conditions grouped in 10 clusters. RESULTS: The mean age of study participants (n = 1097) was 75 years and 48% were women. Overall, cardiometabolic, musculoskeletal, and pulmonary conditions were the most prevalent comorbidity clusters. A high proportion of participants (82%) reported that musculoskeletal conditions exerted the greatest impact on their QoL. Men were more likely than women to report that osteoarthritis and stroke severely impacted their QoL. Patients aged \u3c 75 years were more likely to report that obesity, hip/knee joint problems, and fibromyalgia extremely impacted their QoL than older participants. CONCLUSIONS: Among older persons with AF, while cardiometabolic diseases were highly prevalent, musculoskeletal conditions exerted the greatest impact on patients\u27 disease-specific QoL. Understanding the extent of impairment in QoL due to underlying comorbidities provides an opportunity to develop interventions targeted at diseases that may cause significant impairment in QoL

Association between risk of obstructive sleep apnea and cognitive performance, frailty, and quality of life among older adults with atrial fibrillation

STUDY OBJECTIVES: Geriatric impairments and obstructive sleep apnea (OSA) are prevalent among older patients with atrial fibrillation (AF). Little is known about the association between OSA and geriatric impairments including frailty, cognitive performance, and AF-related quality of life. The objective of this study was to examine the associations of OSA with frailty, cognitive performance, and AF-related quality of life among older adults with AF. METHODS: Data from the Systemic Assessment of Geriatrics Elements-AF study were used which included AF participants 65 years and older and with a CHA2DS2-VASc \u3e /=2. The STOP-BANG questionnaire was used to assess the risk of OSA. Multivariable logistic regression models were used to examine the association between risk of OSA and geriatric impairments, adjusting for sociodemographic, geriatric, and clinical characteristics. RESULTS: A total of 970 participants (mean age 75 years; 51% male) were studied. Of the 680 participants without a medical history of OSA, 26% (n=179) of participants had a low risk of OSA, 53% (n=360) had an intermediate risk, and 21% (n=141) had a high risk for OSA. Compared to those with low risk of OSA, participants with an intermediate or high risk of OSA were more likely to be frail (adjusted odds ratio [aOR]= 1.67, 95% confidence interval [CI]: 1.08-2.56; aOR= 3.00, 95% CI: 1.69-5.32, respectively) in the fully adjusted models. CONCLUSIONS: Our findings identify a group of patients at high risk who would benefit from early screening for OSA. Future longitudinal studies are needed to assess the effect of OSA treatment on frailty, physical functioning, and QoL among patients with AF