What Is the Additive Value of Nutritional Deficiency to Va-Fi in the Risk Assessment For Heart Failure Patients?

OBJECTIVES: to assess the impact of adding the Prognostic Nutritional Index (PNI) to the U.S. Veterans Health Administration frailty index (VA-FI) for the prediction of time-to-death and other clinical outcomes in Veterans hospitalized with Heart Failure. METHODS: A retrospective cohort study of veterans hospitalized for heart failure (HF) from October 2015 to October 2018. Veterans ≥50 years with albumin and lymphocyte counts, needed to calculate the PNI, in the year prior to hospitalization were included. We defined malnutrition as PNI ≤43.6, based on the Youden index. VA-FI was calculated from the year prior to the hospitalization and identified three groups: robust (≤0.1), prefrail (0.1-0.2), and frail (\u3e0.2). Malnutrition was added to the VA-FI (VA-FI-Nutrition) as a 32 RESULTS: We identified 37,601 Veterans hospitalized for HF (mean age: 73.4 ± 10.3 years, BMI: 31.3 ± 7.4 kg/m CONCLUSION: Adding PNI to VA-FI provides a more accurate and comprehensive assessment among Veterans hospitalized for HF. Clinicians should consider adding a specific nutrition algorithm to automated frailty tools to improve the validity of risk prediction in patients hospitalized with HF

Association Between Frailty and Atrial Fibrillation in Older Adults: The Framingham Heart Study Offspring Cohort

Background: Frailty is associated bidirectionally with cardiovascular disease. However, the relations between frailty and atrial fibrillation (AF) have not been fully elucidated. Methods and Results: Using the FHS (Framingham Heart Study) Offspring cohort, we sought to examine both the association between frailty (2005-2008) and incident AF through 2016 and the association between prevalent AF and frailty status (2011-2014). Frailty was defined using the Fried phenotype. Models adjusted for age, sex, and smoking. Cox proportional hazards models, adjusted for competing risk of death, assessed the association between prevalent frailty and incident AF. Logistic regression models assessed the association between prevalent AF and new-onset frailty. For the incident AF analysis, we included 2053 participants (56% women; mean age, 69.7+/-6.9 years). By Fried criteria, 1018 (50%) were robust, 903 (44%) were prefrail, and 132 (6%) were frail. In total, 306 incident cases of AF occurred during an average 9.2 (SD, 3.1) follow-up years. After adjustment, there was no statistically significant association between prevalent frailty status and incident AF (prefrail versus robust: hazard ratio [HR], 1.22 [95% CI, 0.95-1.55]; frail versus robust: HR, 0.92 [95% CI, 0.57-1.47]). At follow-up, there were 111 new cases of frailty. After adjustment, there was no statistically significant association between prevalent AF and new-onset frailty (odds ratio, 0.48 [95% CI, 0.17-1.36]). Conclusions: Although a bidirectional association between frailty and cardiovascular disease has been suggested, we did not find evidence of an association between frailty and AF. Our findings may be limited by sample size and should be further explored in other populations

Association between the AHA Life's Essential 8 score and incident all-cause dementia: a prospective cohort study from UK Biobank

Aim: This study aimed to investigate the association between the LE8 score and incident all-cause dementia (including Alzheimer's disease [AD] and vascular dementia) in UK Biobank. Methods: 259,718 participants were included in this prospective study. Smoking, non-HDL cholesterol, blood pressure, body mass index, HbA1c, physical activity, diet, and sleep were used to create the LE8 score. Associations between the score (both continuous and as quartiles) and outcomes were investigated using adjusted linear and nonlinear Cox proportional hazard models. The potential impact fractions of two scenarios and the rate advancement periods were also calculated. Results: Over a median follow-up of 10.6 years, 4,958 participants were diagnosed with any dementia. Higher LE8 scores were associated with lower risk of all-cause and vascular dementia in an exponential decay pattern. Compared with individuals in the healthiest quartile, those in the least healthy quartile had a higher risk of all-cause dementia (HR: 1.50 [95% CI: 1.37 to 1.65] and vascular dementia (HR: 1.86 [1.44 to 2.42]). A targeted intervention that increased, by 10-points, the score among individuals in the lowest quartile could have prevented 6.8% of all-cause dementia cases. Individuals in the least healthy LE8 quartile might develop all-cause dementia 2.45 years earlier than their counterparts. Conclusions: Individuals with higher LE8 scores had lower risk of all-cause and vascular dementia. Because of nonlinear associations, interventions targeted at the least healthy individuals might produce greater population-level benefits

TAVR in Older Adults: Moving Toward a Comprehensive Geriatric Assessment and Away From Chronological Age

Calcific aortic stenosis can be considered a model for geriatric cardiovascular conditions due to a confluence of factors. The remarkable technological development of transcatheter aortic valve replacement was studied initially on older adult populations with prohibitive or high-risk for surgical valve replacement. Through these trials, the cardiovascular community has recognized that stratification of these chronologically older adults can be improved incrementally by invoking the concept of frailty and other geriatric risks. Given the complexity of the aging process, stratification by chronological age should only be the initial step but is no longer sufficient to optimally quantify cardiovascular and noncardiovascular risk. In this review, we employ a geriatric cardiology lens to focus on the diagnosis and the comprehensive management of aortic stenosis in older adults to enhance shared decision-making with patients and their families and optimize patient-centered outcomes. Finally, we highlight knowledge gaps that are critical for future areas of study

Life\u27s Essential 8: Optimizing Health in Older Adults

The population worldwide is getting older as a result of advances in public health, medicine, and technology. Older individuals are living longer with a higher prevalence of subclinical and clinical cardiovascular disease (CVD). In 2010, the American Heart Association introduced a list of key prevention targets, known as Life\u27s Simple 7 to increase CVD-free survival, longevity, and quality of life. In 2022, sleep health was added to expand the recommendations to Life\u27s Essential 8 (eat better, be more active, stop smoking, get adequate sleep, manage weight, manage cholesterol, manage blood pressure, and manage diabetes). These prevention targets are intended to apply regardless of chronologic age. During this same time, the understanding of aging biology and goals of care for older adults further enhanced the relevance of prevention across the range of functions. From a biological perspective, aging is a complex cellular process characterized by genomic instability, telomere attrition, loss of proteostasis, inflammation, deregulated nutrient-sensing, mitochondrial dysfunction, cellular senescence, stem cell exhaustion, and altered intercellular communication. These aging hallmarks are triggered by and enhanced by traditional CVD risk factors leading to geriatric syndromes (eg, frailty, sarcopenia, functional limitation, and cognitive impairment) which complicate efforts toward prevention. Therefore, we review Life\u27s Essential 8 through the lens of aging biology, geroscience, and geriatric precepts to guide clinicians taking care of older adults

Frailty in inflammatory bowel diseases: an emerging concept.

Inflammatory bowel diseases (IBD), consisting of Crohn's disease and ulcerative colitis, are chronic remitting, relapsing inflammatory conditions of the gastrointestinal tract. While traditionally a disease of younger ages, the number of older adults with IBD is rising rapidly. Patients with IBD often experience geriatric syndromes at earlier ages. Older adults with IBD have poorer disease and treatment-related outcomes compared with younger adults with IBD. Applying the principles of geriatrics to understanding a chronic disease in older adults may improve health span. Better tools are needed to stratify IBD patients who are at high risk for adverse events. Frailty is a geriatric construct that may approximate biologic age. Frailty is a complex, multi-dimensional syndrome that leads to increased vulnerability to stress and decline of reserve across multiple physiologic systems. In this review, we present the leading conceptual models of frailty and discuss the applications of frailty in immune-mediated diseases. We also review chronic conditions where frailty has been applied successfully as a tool for risk stratification. Finally, we discuss in the detail the growing body of literature highlighting the relationship between frailty and IBD, the epidemiology of frailty in IBD, and ramifications of frailty in IBD

One Step at a Time: Improving Gait Speed Measurement in a Geriatric Medicine Clinic

(1) Background: Mobility assessment is a key component of the assessment of an older adult as a part of the Age-Friendly Health System (AFHS) “geriatric 4Ms” framework. Several validated tools for assessing mobility and estimating fall risk in older adults are available. However, they are often under-utilized in daily practice even in specialty geriatric medicine care settings. We aimed to increase formal mobility assessment with brief gait speed measurement in a geriatric medicine outpatient clinic using phased change interventions. (2) Methods: This quality improvement (QI) initiative was conducted in a single outpatient geriatric medicine clinic. All clinic attendees who could complete a gait speed measurement were eligible for inclusion. The outcome measure was the completion of a 4 m gait speed. Several change interventions were implemented on a phased basis using the Model for Improvement methodology during the period from December 2018 to March 2020. Statistical process control charts were used to record gait speed measurements and detect non-random shifts. (3) Results: During this QI initiative, 80 patients were seen, accounting for 142 clinic visits. In response to change interventions, gait speed measurement at clinic visits increased from a median of 25% of visits to 67% by March 2020. (4) Conclusions: Adopting an AFHS care model is an urgent and challenging task to improve the quality of care for older adults. This initiative details how to effectively incorporate a brief, validated assessment of mobility using gait speed measurement into every geriatric medicine outpatient visit and progresses implementation of the AFHS “geriatric 4Ms”. Mobility assessment can aid in identifying older adults at increased fall risk

Feasibility of frailty screening among patients with advanced heart failure

Background Frailty is common among patients with advanced heart failure (HF), and screening for frailty to guide care is recommended. Although multiple tools are available to screen for frailty, the feasibility of routinely incorporating frailty screening into daily clinical practice among hospitalised advanced HF patients has not been rigorously tested.Methods This was a prospective, single-centre, quality improvement study. Two brief frailty screening tools were incorporated into palliative care consultations for all patients ≥50 years from August 2021 to October 2022. In the first phase, the Clinical Frailty Scale (CFS) was implemented, followed by the Study of Osteoporotic Fracture (SOF) tool or a modified SOF (mSOF) version in the second phase. The primary outcome was feasibility (%) of performing frailty screenings for this high-risk population.Results A total of 212 patients (mean age 69±10 years, 69% male, 79% white, 30% with ischaemic HF) were referred for palliative care consultation during the study period. Overall, frailty screens were completed in 86% (n=183) of patients. CFS and mSOF reached >80% of adoption, while SOF adoption was 54%. Altogether, 52% of the population screened frail by use of CFS and 52% also by mSOF. All clinicians (n=6) participating in the study reported that frailty screening tools were useful and acceptable, and 83% reported plans for continued utilisation in future clinical practice.Conclusions Frailty screening with CFS or mSOF tools was feasible in hospitalised patients with advanced HF. Tools that require physical assessment were more challenging to implement. These data support the feasibility of incorporating questionnaire-based frailty screening in a busy hospital setting

Challenges for patients dying of heart failure and cancer

Background: Hospice and palliative care were originally implemented for patients dying of cancer, both of which continue to be underused in patients with heart failure (HF). The objective of this study was to understand the unique challenges faced by patients dying of HF compared with cancer. Methods: We assessed differences in demographics, health status, and financial burden between patients dying of HF and cancer from the Health and Retirement Study. Results: The analysis included 3203 individuals who died of cancer and 3555 individuals who died of HF between 1994 and 2014. Compared with patients dying of cancer, patients dying of HF were older (80 years versus 76 years), had poorer self-reported health, and had greater difficulty with all activities of daily living while receiving less informal help. Their death was far more likely to be considered unexpected (39% versus 70%) and they were much more likely to have died without warning or within 1 to 2 hours (20% versus 1%). They were more likely to die in a hospital or nursing home than at home or in hospice. Both groups faced similarly high total healthcare out-of-pockets costs ($9988 versus$9595, P=0.6) though patients dying of HF had less wealth ($29 895 versus$39 008), thereby experiencing greater financial burden. Conclusions: Compared with patients dying of cancer, those dying from HF are older, have greater difficulty with activities of daily living, are more likely to die suddenly, in a hospital or nursing home rather than home or hospice, and had worse financial burden