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Srichawla BS, Hamel AP, Cook P, Aleyadeh R, Lessard D, Otabil EM, Mehawej J, Saczynski JS, McManus DD, Moonis M. Is catheter ablation associated with preservation of cognitive function? An analysis from the SAGE-AF observational cohort study. Front Neurol 2024; 14:1302020. [PMID: 38249728 PMCID: PMC10799336 DOI: 10.3389/fneur.2023.1302020] [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] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 12/14/2023] [Indexed: 01/23/2024] Open
Abstract
Objectives To examine the associations between catheter ablation treatment (CA) vs. medical management and cognitive impairment among older adults with atrial fibrillation (AF). Methods Ambulatory patients who had AF, were ≥65-years-old, and were eligible to receive oral anticoagulation could be enrolled into the SAGE (Systematic Assessment of Geriatric Elements)-AF study from internal medicine and cardiology clinics in Massachusetts and Georgia between 2016 and 2018. Cognitive function was assessed using the Montreal Cognitive Assessment (MoCA) tool at baseline, 1-, and 2 years. Cognitive impairment was defined as a MoCA score ≤ 23. Multivariate-adjusted logistic regression of longitudinal repeated measures was used to examine associations between treatment with CA vs. medical management and cognitive impairment. Results 887 participants were included in this analysis. On average, participants were 75.2 ± 6.7 years old, 48.6% women, and 87.4% white non-Hispanic. 193 (21.8%) participants received a CA before enrollment. Participants who had previously undergone CA were significantly less likely to be cognitively impaired during the 2-year study period (aOR 0.70, 95% CI 0.50-0.97) than those medically managed (i.e., rate and/or rhythm control), even after adjusting with propensity score for CA. At the 2-year follow-up a significantly greater number of individuals in the non-CA group were cognitively impaired (MoCA ≤ 23) compared to the CA-group (311 [44.8%] vs. 58 [30.1%], p = 0.0002). Conclusion In this 2-year longitudinal prospective cohort study participants who underwent CA for AF before enrollment were less likely to have cognitive impairment than those who had not undergone CA.
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Affiliation(s)
- Bahadar S. Srichawla
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA, United States
| | - Alexander P. Hamel
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, United States
| | - Philip Cook
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, United States
| | - Rozaleen Aleyadeh
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA, United States
| | - Darleen Lessard
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, United States
| | - Edith M. Otabil
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, United States
| | - Jordy Mehawej
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, United States
| | - Jane S. Saczynski
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, United States
| | - David D. McManus
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, United States
| | - Majaz Moonis
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA, United States
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Ding EY, Tran KV, Lessard D, Wang Z, Han D, Mohagheghian F, Mensah Otabil E, Noorishirazi K, Mehawej J, Filippaios A, Naeem S, Gottbrecht MF, Fitzgibbons TP, Saczynski JS, Barton B, Chon K, McManus DD. Accuracy, Usability, and Adherence of Smartwatches for Atrial Fibrillation Detection in Older Adults After Stroke: Randomized Controlled Trial. JMIR Cardio 2023; 7:e45137. [PMID: 38015598 DOI: 10.2196/45137] [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] [Received: 12/16/2022] [Revised: 05/31/2023] [Accepted: 06/19/2023] [Indexed: 11/29/2023] Open
Abstract
BACKGROUND Atrial fibrillation (AF) is a common cause of stroke, and timely diagnosis is critical for secondary prevention. Little is known about smartwatches for AF detection among stroke survivors. We aimed to examine accuracy, usability, and adherence to a smartwatch-based AF monitoring system designed by older stroke survivors and their caregivers. OBJECTIVE This study aims to examine the feasibility of smartwatches for AF detection in older stroke survivors. METHODS Pulsewatch is a randomized controlled trial (RCT) in which stroke survivors received either a smartwatch-smartphone dyad for AF detection (Pulsewatch system) plus an electrocardiogram patch or the patch alone for 14 days to assess the accuracy and usability of the system (phase 1). Participants were subsequently rerandomized to potentially 30 additional days of system use to examine adherence to watch wear (phase 2). Participants were aged 50 years or older, had survived an ischemic stroke, and had no major contraindications to oral anticoagulants. The accuracy for AF detection was determined by comparing it to cardiologist-overread electrocardiogram patch, and the usability was assessed with the System Usability Scale (SUS). Adherence was operationalized as daily watch wear time over the 30-day monitoring period. RESULTS A total of 120 participants were enrolled (mean age 65 years; 50/120, 41% female; 106/120, 88% White). The Pulsewatch system demonstrated 92.9% (95% CI 85.3%-97.4%) accuracy for AF detection. Mean usability score was 65 out of 100, and on average, participants wore the watch for 21.2 (SD 8.3) of the 30 days. CONCLUSIONS Our findings demonstrate that a smartwatch system designed by and for stroke survivors is a viable option for long-term arrhythmia detection among older adults at risk for AF, though it may benefit from strategies to enhance adherence to watch wear. TRIAL REGISTRATION ClinicalTrials.gov NCT03761394; https://clinicaltrials.gov/study/NCT03761394. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) RR2-10.1016/j.cvdhj.2021.07.002.
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Affiliation(s)
- Eric Y Ding
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, United States
| | - Khanh-Van Tran
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, United States
| | - Darleen Lessard
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA, United States
| | - Ziyue Wang
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, United States
| | - Dong Han
- Department of Bioengineering, University of Connecticut, Storrs, CT, United States
| | - Fahimeh Mohagheghian
- Department of Bioengineering, University of Connecticut, Storrs, CT, United States
| | - Edith Mensah Otabil
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, United States
| | - Kamran Noorishirazi
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, United States
| | - Jordy Mehawej
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, United States
| | - Andreas Filippaios
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, United States
| | - Syed Naeem
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, United States
| | - Matthew F Gottbrecht
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, United States
| | - Timothy P Fitzgibbons
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, United States
| | - Jane S Saczynski
- Department of Pharmacy and Health Systems Sciences, Northeastern University, Boston, MA, United States
| | - Bruce Barton
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA, United States
| | - Ki Chon
- Department of Bioengineering, University of Connecticut, Storrs, CT, United States
| | - David D McManus
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, United States
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Srichawla BS, Hamel AP, Cook P, Aleyadeh R, Lessard D, Otabil EM, Mehawej J, Saczynski JS, McManus DD, Moonis M. Is Catheter Ablation Associated with Preservation of Cognitive Function? An Analysis From the SAGE-AF Observational Cohort Study. medRxiv 2023:2023.11.20.23298768. [PMID: 38045229 PMCID: PMC10690357 DOI: 10.1101/2023.11.20.23298768] [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] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/05/2023]
Abstract
Objectives To examine the associations between catheter ablation treatment (CA) versus medical management and cognitive impairment among older adults with atrial fibrillation (AF). Methods Ambulatory patients who had AF, were ≥ 65-years-old, and were eligible to receive oral anticoagulation could be enrolled into the SAGE (Systematic Assessment of Geriatric Elements)-AF study from internal medicine and cardiology clinics in Massachusetts and Georgia between 2016 and 2018. Cognitive function was assessed using the Montreal Cognitive Assessment (MoCA) tool at baseline, one-, and two years. Cognitive impairment was defined as a MoCA score ≤ 23. Multivariate-adjusted logistic regression of longitudinal repeated measures was used to examine associations between treatment with CA vs. medical management and cognitive impairment. Results 887 participants were included in this analysis. On average, participants were 75.2 ± 6.7 years old, 48.6% women, and 87.4% white non-Hispanic. 193 (21.8%) participants received a CA before enrollment. Participants who had previously undergone CA were significantly less likely to be cognitively impaired during the two-year study period (aOR 0.70, 95% CI 0.50-0.97) than those medically managed (i.e., rate and/or rhythm control), even after adjusting with propensity score for CA. At the two-year follow-up a significantly greater number of individuals in the non-CA group were cognitively impaired (MoCA ≤ 23) compared to the CA-group (311 [44.8%] vs. 58 [30.1%], p=0.0002). Conclusions In this two-year longitudinal prospective cohort study participants who underwent CA for AF before enrollment were less likely to have cognitive impairment than those who had not undergone CA.
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Affiliation(s)
- Bahadar S. Srichawla
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA, U.S.A
| | - Alexander P. Hamel
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, U.S.A
| | - Philip Cook
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, U.S.A
| | - Rozaleen Aleyadeh
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA, U.S.A
| | - Darleen Lessard
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, U.S.A
| | - Edith M. Otabil
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, U.S.A
| | - Jordy Mehawej
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, U.S.A
| | - Jane S. Saczynski
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, U.S.A
| | - David D. McManus
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, U.S.A
| | - Majaz Moonis
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA, U.S.A
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Pierre-Louis IC, Saczynski JS, Lopez-Pintado S, Waring ME, Abu HO, Goldberg RJ, Kiefe CI, Helm R, McManus DD, Bamgbade BA. Characteristics associated with poor atrial fibrillation-related quality of life in adults with atrial fibrillation. J Cardiovasc Med (Hagerstown) 2023; 24:422-429. [PMID: 37129916 PMCID: PMC10699883 DOI: 10.2459/jcm.0000000000001479] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
PURPOSE Few studies have examined the relationship between poor atrial fibrillation-related quality of life (AFQoL) and a battery of geriatric factors. The objective of this study is to describe factors associated with poor AFQoL in older adults with atrial fibrillation (AF) with a focus on sociodemographic and clinical factors and a battery of geriatric factors. METHODS Cross-sectional analysis of a prospective cohort study of participants aged 65+ with high stroke risk and AF. AFQoL was measured using the validated Atrial Fibrillation Effect on Quality of Life (score 0-100) and categorized as poor (<80) or good (80-100). Chi-square and t -tests evaluated differences in factors across poor AFQoL and significant characteristics ( P < 0.05) were entered into a logistic regression model to identify variables related to poor AFQoL. RESULTS Of 1244 participants (mean age 75.5), 42% reported poor AFQoL. Falls in the past 6 months, pre/frail and frailty, depression, anxiety, social isolation, vision impairment, oral anticoagulant therapy, rhythm control, chronic obstructive pulmonary disease and polypharmacy were associated with higher odds of poor AFQoL. Marriage and college education were associated with a lower odds of poor AFQoL. CONCLUSIONS More than 4 out of 10 older adults with AF reported poor AFQoL. Geriatric factors associated with higher odds of reporting poor AFQoL include recent falls, frailty, depression, anxiety, social isolation and vision impairment. Findings from this study may help clinicians screen for patients with poor AFQoL who could benefit from tailored management to ensure the delivery of patient-centered care and improved well being among older adults with AF.
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Affiliation(s)
| | - Jane S. Saczynski
- Department of Pharmacy and Health Systems Sciences, School of Pharmacy
| | | | - Molly E. Waring
- Department of Allied Health Sciences, University of Connecticut, Storrs, CT
| | - Hawa O. Abu
- Division of Cardiovascular Medicine, Department of Medicine, UMass Chan Medical School, Worcester
- Internal Medicine Department Saint Vincent Hospital, Worcester
| | - Robert J. Goldberg
- Department of Population and Quantitative Health Sciences, UMass Chan Medical School, Worcester
| | - Catarina I. Kiefe
- Department of Population and Quantitative Health Sciences, UMass Chan Medical School, Worcester
| | - Robert Helm
- Department of Radiology, Boston University, Boston, MA, USA
| | - David D. McManus
- Division of Cardiovascular Medicine, Department of Medicine, UMass Chan Medical School, Worcester
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5
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Wang W, Lessard D, Kiefe CI, Goldberg RJ, Parish D, Helm R, Trymbulak K, Mehawej J, Abu H, Bamgbade BA, Hayward R, Gore J, Gurwitz JH, McManus DD, Saczynski JS. Cover. J Am Geriatr Soc 2023. [DOI: 10.1111/jgs.17236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
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Wang W, Lessard D, Kiefe CI, Goldberg RJ, Parish D, Helm R, Trymbulak K, Mehawej J, Abu H, Bamgbade BA, Hayward R, Gore J, Gurwitz JH, McManus DD, Saczynski JS. Differential effect of anticoagulation according to cognitive function and frailty in older patients with atrial fibrillation. J Am Geriatr Soc 2023; 71:394-403. [PMID: 36273408 PMCID: PMC10207283 DOI: 10.1111/jgs.18079] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [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: 04/05/2022] [Revised: 08/29/2022] [Accepted: 09/02/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND In older patients with atrial fibrillation (AF), cognitive impairment and frailty are prevalent. It is unknown whether the risk and benefit of anticoagulation differ by cognitive function and frailty. METHODS A total of 1244 individuals with AF with age ≥65 years and a CHADSVASC score ≥2 were recruited from clinics in Massachusetts and Georgia between 2016 and 18 and followed until 2020. At baseline, frailty status and cognitive function were assessed. Hazard ratios of anticoagulation on physician adjudicated outcomes were adjusted by the propensity for receiving anticoagulation and stratified by cognitive function and frailty status. RESULTS The average age was 75.5 (± 7.1) years, 49% were women, and 86% were prescribed oral anticoagulants. At baseline, 528 (42.4%) participants were cognitively impaired and 172 (13.8%) were frail. The adjusted hazard ratios of anticoagulation for the composite of major bleeding or death were 2.23 (95% confidence interval: 1.08-4.61) among cognitively impaired individuals and 0.94 (95% confidence interval: 0.49-1.79) among cognitively intact individuals (P for interaction = 0.08). Adjusted hazard ratios for anticoagulation were 1.84 (95% confidence interval: 0.66-5.13) among frail individuals and 1.39 (95% confidence interval: 0.84-2.40) among not frail individuals (P for interaction = 0.67). CONCLUSION Compared with no anticoagulation, anticoagulation is associated with more major bleeding episodes and death in older patients with AF who are cognitively impaired.
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Affiliation(s)
- Weijia Wang
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Darleen Lessard
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Catarina I. Kiefe
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Robert J. Goldberg
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - David Parish
- Department of Medicine, School of Medicine, Mercer University, Macon, GA
| | - Robert Helm
- Department of Medicine, School of Medicine, Boston University, Boston, MA
| | - Katherine Trymbulak
- Frank H. Netter M.D. School of Medicine at Quinnipiac University, North Haven, CT USA
| | - Jordy Mehawej
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Hawa Abu
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Benita A. Bamgbade
- Department of Pharmacy and Health System Sciences, Northeastern University, Boston, MA
| | - Robert Hayward
- Kaiser Permanente Santa Clara Medical Center, Santa Clara, CA
| | - Joel Gore
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Jerry H. Gurwitz
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
- Meyers Primary Care Institute, University of Massachusetts Medical School, Worcester, MA, USA
| | - David D. McManus
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Jane S. Saczynski
- Department of Pharmacy and Health System Sciences, Northeastern University, Boston, MA
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Bamgbade BA, McManus DD, Briesacher BA, Lessard D, Mehawej J, Gurwitz JH, Tisminetzky M, Mujumdar S, Wang W, Malihot T, Abu HO, Waring M, Sogade F, Madden J, Pierre-Louis IC, Helm R, Goldberg R, Kramer AF, Saczynski JS. Medication cost-reducing behaviors in older adults with atrial fibrillation: The SAGE-AF study. J Am Pharm Assoc (2003) 2023; 63:125-134. [PMID: 36171156 PMCID: PMC10699884 DOI: 10.1016/j.japh.2022.08.030] [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] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 08/25/2022] [Accepted: 08/31/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND As patient prices for many medications have risen steeply in the United States, patients may engage in cost-reducing behaviors (CRBs) such as asking for generic medications or purchasing medication from the Internet. OBJECTIVE The objective of this study is to describe patterns of CRB, cost-related medication nonadherence, and spending less on basic needs to afford medications among older adults with atrial fibrillation (AF) and examine participant characteristics associated with CRB. METHODS Data were from a prospective cohort study of older adults at least 65 years with AF and a high stroke risk (CHA2DS2VASc ≥ 2). CRB, cost-related medication nonadherence, and spending less on basic needs to afford medications were evaluated using validated measures. Chi-square and t tests were used to evaluate differences in characteristics across CRB, and statistically significant characteristics (P < 0.05) were entered into a multivariable logistic regression to examine factors associated with CRB. RESULTS Among participants (N = 1224; mean age 76 years; 49% female), 69% reported engaging in CRB, 4% reported cost-related medication nonadherence, and 6% reported spending less on basic needs. Participants who were cognitively impaired (adjusted odds ratio 0.69 [95% CI 0.52-0.91]) and those who did not identify as non-Hispanic white (0.66 [0.46-0.95]) were less likely to engage in CRB. Participants who were married (1.88 [1.30-2.72]), had a household income of $20,000-$49,999 (1.52 [1.02-2.27]), had Medicare insurance (1.38 [1.04-1.83]), and had 4-6 comorbidities (1.43 [1.01-2.01]) had significantly higher odds of engaging in CRB. CONCLUSION Although CRBs were common among older adults with AF, few reported cost-related medication nonadherence and spending less on basic needs. Patients with cognitive impairment may benefit from pharmacist intervention to provide support in CRB and patient assistance programs.
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Affiliation(s)
- Benita A. Bamgbade
- Department of Pharmacy and Health System Sciences, Northeastern University, Boston, MA
| | - David D. McManus
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester, MA; and Professor, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA
| | - Becky A. Briesacher
- Department of Pharmacy and Health System Sciences, Northeastern University, Boston, MA
| | - Darleen Lessard
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester, MA; and Biostatistician, Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA
| | - Jordy Mehawej
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester, MA
| | - Jerry H. Gurwitz
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA; Executive Director, Meyers Health Care Institute, Worcester, MA; and Professor, Division of Geriatric Medicine, University of Massachusetts Medical School, Worcester, MA
| | - Mayra Tisminetzky
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA; and Associate Professor, Division of Geriatric Medicine, University of Massachusetts Medical School, Worcester, MA
| | | | - Weija Wang
- Department of Cardiology, Johns Hopkins Hospital, Baltimore, MD
| | - Tanya Malihot
- Faculty of Nursing, Universite de Montreal, Montreal, Quebec, Canada; and Member, Montreal Heart Institute Research Center, Montreal, Quebec, Canada
| | - Hawa O. Abu
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester, MA
| | - Molly Waring
- Department of Allied Health Sciences, University of Connecticut, Storrs, CT
| | - Felix Sogade
- Department of Medicine, Mercer University School of Medicine, Mercer, GA
| | - Jeanne Madden
- Department of Pharmacy and Health System Sciences, Northeastern University, Boston, MA
| | | | - Robert Helm
- Cardiovascular Medicine, Department of Medicine, School of Medicine, Boston University, Boston, MA
| | - Robert Goldberg
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA
| | - Arthur F. Kramer
- Department of Psychology, Northeastern University, Boston, MA; and Professor, Beckman Institute, University of Illinois at Urbana-Champaign, Urbana, IL
| | - Jane S. Saczynski
- Department of Pharmacy and Health System Sciences, Northeastern University, Boston, MA
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Wang W, Saczynski JS, Lessard D, Goldberg RJ, Parish D, Helm R, Kiefe CI, Trymbulak K, Mehawej J, Abu H, Hayward R, Gore J, Gurwitz JH, McManus DD. Presence of Geriatric Conditions Is Prognostic of Major Bleeding in Older Patients with Atrial Fibrillation: a Cohort Study. J Gen Intern Med 2022; 37:3893-3899. [PMID: 35102482 PMCID: PMC9640487 DOI: 10.1007/s11606-022-07410-x] [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: 09/14/2021] [Accepted: 01/07/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND In older patients with atrial fibrillation (AF), physical, cognitive, and psychosocial limitations are prevalent. The prognostic value of these conditions for major bleeding is unclear. OBJECTIVE To determine whether geriatric conditions are prospectively associated with major bleeding in older patients with AF on anticoagulation. DESIGN Multicenter cohort study with 2-year follow-up from 2016 to 2020 in Massachusetts and Georgia from cardiology, electrophysiology, and primary care clinics. PARTICIPANTS Diagnosed with AF, age 65 years or older, CHA2DS2-VASc score of 2 or higher, and taking oral anticoagulant (n=1,064). A total of 6507 individuals were screened. MAIN MEASURES A six-component geriatric assessment of frailty, cognitive function, social support, depressive symptoms, vision, and hearing. Main outcome was major bleeding adjudicated by a physician panel. KEY RESULTS At baseline, participants were, on average, 75.5 years old and 49% were women. Mean CHA2DS2-VASc score was 4.5 and the mean HAS-BLED score was 3.3. During 2.0 (± 0.4) years of follow-up, 95 (8.9%) participants developed an episode of major bleeding. After adjusting for key covariates and accounting for competing risk from death, cognitive impairment (hazard ratio [HR] 1.62, 95% confidence interval [CI]: 1.02-2.56) and frailty (HR 2.77, 95% CI 1.38-5.58) were significantly associated with the development of major bleeding. CONCLUSIONS In older patients with AF taking anticoagulants, cognitive impairment and frailty were independently associated with major bleeding.
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Affiliation(s)
- Weijia Wang
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA.
| | - Jane S Saczynski
- Department of Pharmacy and Health System Sciences, Northeastern University, Boston, MA, USA
| | - Darleen Lessard
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Robert J Goldberg
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - David Parish
- Department of Medicine, School of Medicine, Mercer University, Macon, GA, USA
| | - Robert Helm
- Department of Medicine, School of Medicine, Boston University, Boston, MA, USA
| | - Catarina I Kiefe
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Katherine Trymbulak
- Frank H. Netter M.D. School of Medicine at Quinnipiac University, North Haven, CT, USA
| | - Jordy Mehawej
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Hawa Abu
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Robert Hayward
- Kaiser Permanente Santa Clara Medical Center, Santa Clara, CA, USA
| | - Joel Gore
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Jerry H Gurwitz
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
- Meyers Health Care Institute, University of Massachusetts Medical School, Worcester, MA, USA
| | - David D McManus
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
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9
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Dai Q, Mehawej J, Saczynski JS, Tran KV, Abu HO, Lessard D, Fillippaios A, Paul T, Hariri E, Wang W, Tisminetzky M, Soni A, Howard-Wilson S, Waring ME, Goldberg RJ, McManus DD. Usefulness of Self-Reported Physical Activity and Clinical Outcomes in Older Patients With Atrial Fibrillation. Am J Cardiol 2022; 181:32-37. [PMID: 35985871 PMCID: PMC10427165 DOI: 10.1016/j.amjcard.2022.07.010] [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: 05/16/2022] [Revised: 06/29/2022] [Accepted: 07/05/2022] [Indexed: 11/18/2022]
Abstract
Current guidelines encourage regular physical activity (PA) to gain cardiovascular health benefit. However, little is known about whether older adults with atrial fibrillation (AF) who engage in the guideline-recommended level of PA are less likely to experience clinically relevant outcomes. We did a retrospective study based on the data from Systemic Assessment of Geriatric Elements in AF (SAGE-AF) prospective cohort study. The study population consisted of older participants with AF (≥65 years) and a congestive heart failure, hypertension, age, diabetes, stroke vascular disease, age 65 to 75 and sex(CHA2DS2-VASc) score ≥2. PA was quantified by self-reported Minnesota Leisure Time PA questionnaire. Competing risk models were used to examine the association between PA level and clinical outcomes over 2 years while controlling for several potentially confounding variables. A total of 1,244 participants (average age 76 years; 51% men; 85% non-Hispanic White) were studied. A total of 50.5% of participants engaged in regular PA. Meeting the recommended level of PA was associated with lower mortality over 2 years (adjusted hazard ratio 0.60, 95% confidence interval 0.38 to 0.95) but was not associated with rates of stroke or major bleeding. In conclusion, older adults with AF who engaged in guideline-recommended PA are more likely to survive in the long term. Healthcare providers should promote and encourage engagement in PA and tailor interventions to address barriers of engagement.
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Affiliation(s)
- Qiying Dai
- Division of Cardiology, Department of Medicine, Saint Vincent Hospital, Worcester, Massachusetts.
| | - Jordy Mehawej
- Division of Cardiovascular Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Jane S Saczynski
- Department of Pharmacy and Health Systems Sciences, School of Pharmacy, Northeastern University, Boston, Massachusetts
| | - Khanh-Van Tran
- Division of Cardiovascular Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Hawa O Abu
- Division of Cardiology, Department of Medicine, Saint Vincent Hospital, Worcester, Massachusetts
| | - Darleen Lessard
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Andreas Fillippaios
- Division of Cardiovascular Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Tenes Paul
- Division of Cardiovascular Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Essa Hariri
- Department of Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Weijia Wang
- Department of Cardiology, Johns Hopkins Hospital, Baltimore, Maryland
| | - Mayra Tisminetzky
- Division of Geriatrics, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Apurv Soni
- Division of Cardiovascular Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Sakeina Howard-Wilson
- Division of Cardiovascular Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Molly E Waring
- Department of Allied Health Sciences, University of Connecticut, Storrs, Connecticut
| | - Robert J Goldberg
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - David D McManus
- Division of Cardiovascular Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
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Abu HO, Wang W, Otabil EM, Saczynski JS, Mehawej J, Mishra A, Tisminetzky M, Blanchard G, Gurwitz JH, Goldberg RJ, McManus DD. Perception of atrial fibrillation symptoms: Impact on quality of life and treatment in older adults. J Am Geriatr Soc 2022; 70:2805-2817. [PMID: 35791806 PMCID: PMC9588564 DOI: 10.1111/jgs.17954] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Revised: 05/09/2022] [Accepted: 06/08/2022] [Indexed: 01/19/2023]
Abstract
BACKGROUND In managing older adults with atrial fibrillation (AF), their symptomatology impacts their well-being and may inform treatment decision-making. We examined AF symptom perception, its impact on quality of life (QoL), and its relation to treatment strategies in older adults with AF. METHODS Data were obtained from older adults with AF enrolled in a multicenter study conducted at clinic sites in Massachusetts and Georgia between 2016 and 2018. Participants were stratified into three age groups: 65-74 (youngest-old), 75-84 (middle-old), and ≥85 (oldest). Perception of AF symptoms was assessed by participant self-report during their clinic visit and at study enrollment by the Atrial Fibrillation Effect on Quality-of-Life Questionnaire which assessed cardiac-specific and non-specific, non-cardiac AF symptoms and their impact on QoL. Treatment strategies (rate or rhythm control) utilized were ascertained from electronic medical records. RESULTS Among the 1184 participants (mean age 75 years, 48% women, 86% Non-Hispanic White), 51% were aged 65-74 years, 36% were 75-84 years, and 13% were ≥ 85 years. The most commonly reported AF symptoms were non-specific, non-cardiac symptoms (fatigue, dyspnea, lightheadedness) with similar prevalence and impact on QoL in all age groups. Cardiac-specific AF symptoms (palpitations, irregular heartbeat, pause in heart activity) were less prevalent, but most commonly reported by the youngest participants (65-74 years), who endorsed considerable impact of these symptoms on their QoL. Overall, those who reported experiencing any AF symptoms during their clinic visit were more likely to have received rhythm compared with rate control (OR: 1.56; 95% CI: 1.18-2.04) with similar findings for all age groups except those aged ≥85 years. CONCLUSIONS Our findings suggest a high prevalence of non-specific, non-cardiac symptoms among older adults with AF and that cardiac-specific AF symptoms may exert considerable impact on their QoL. The presence of any AF symptoms may drive more rhythm control in a majority of older adults.
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Affiliation(s)
- Hawa O. Abu
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester MA
- Department of Internal Medicine, Saint Vincent Hospital, Worcester MA
| | - Weijia Wang
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester MA
| | - Edith M. Otabil
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester MA
| | - Jane S. Saczynski
- Department of Pharmacy and Health Systems Sciences, School of Pharmacy, Northeastern University, Boston MA
| | - Jordy Mehawej
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester MA
| | - Ajay Mishra
- Department of Internal Medicine, Saint Vincent Hospital, Worcester MA
| | - Mayra Tisminetzky
- Division of Geriatric Medicine and Meyers Health Care Institute. Department of Medicine, University of Massachusetts Medical School, Worcester MA
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA
| | - Gary Blanchard
- Division of Geriatrics, Department of Internal Medicine, Saint Vincent Hospital, Worcester MA
| | - Jerry H. Gurwitz
- Division of Geriatric Medicine and Meyers Health Care Institute. Department of Medicine, University of Massachusetts Medical School, Worcester MA
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA
| | - Robert J. Goldberg
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA
| | - David D. McManus
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester MA
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11
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Karnik AA, Saczynski JS, Chung JJ, Gurwitz JH, Bamgbade BA, Paul TJ, Lessard DM, McManus DD, Helm RH. Cognitive impairment, age, quality of life, and treatment strategy for atrial fibrillation in older adults: The SAGE-AF study. J Am Geriatr Soc 2022; 70:2818-2826. [PMID: 35735210 PMCID: PMC10719956 DOI: 10.1111/jgs.17886] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [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: 01/21/2022] [Revised: 04/18/2022] [Accepted: 04/23/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) treatment includes anticoagulation for high stroke risk individuals and either rate or rhythm control strategies. We aimed to investigate the impact of age, geriatric factors, and medical comorbidities on choice of rhythm versus rate control strategy in older adults. METHODS Patients with AF aged ≥65 years with CHA2 DS2 VASc score ≥2 and eligible for anticoagulation were recruited for the Systematic Assessment of Geriatric Elements-AF (SAGE-AF) prospective cohort study. An interview that included measures of HRQoL, cognitive function, vision, hearing, and frailty was performed. The association between these elements and AF treatment strategy was examined by multivariable logistic regression models. RESULTS One thousand two hundred forty-four participants (mean age 76 years; 49% female; 85% non-Hispanic white) were enrolled. Rate and rhythm control were used in 534 and 710 participants, respectively. Compared to participants <75 years, those ≥75 were more likely to be treated with a rate control strategy (age 75-84 adjusted odds ratio [aOR] 1.37 [95% CI 0.99, 1.88]; age 85+ aOR = 2.05, 95% CI 1.30, 3.21). Those treated with a rate control strategy were more likely to have cognitive impairment (aOR = 1.50, 95% CI 1.13, 1.99), and peripheral vascular disease (PVD) (aOR = 1.82, 95% CI 1.22, 2.72) but less likely to have visual impairment (aOR 0.73 [0.55, 0.98]), congestive heart failure (CHF; aOR 0.68 [0.49, 0.94]) or receive anticoagulation (aOR 0.53, 95% CI 0.36, 0.78). CONCLUSION Older age, cognitive impairment, and PVD were associated with use of rate control strategy. Visual impairment, CHF, and anticoagulation use were associated with a rhythm control strategy. There was no difference in HRQoL between the rate and rhythm control groups. This study suggests that certain geriatric elements may be associated with AF treatment strategies. Further study is needed to evaluate how these decisions affect outcomes.
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Affiliation(s)
- Ankur A. Karnik
- Evans Department of Medicine, Cardiovascular Medicine Section, Arrhythmia Service, Boston University School of Medicine, Boston, MA
| | - Jane S. Saczynski
- Bouvé College of Health Sciences, Department of Pharmacy and Health System Sciences, Northeastern University, Boston, MA
| | - Joseph J. Chung
- Evans Department of Medicine, Boston University School of Medicine, Boston, MA
| | - Jerry H. Gurwitz
- Meyers Primary Care Institute and Division of Geriatric Medicine, University of Massachusetts Medical School, Worcester, MA
| | - Benita A. Bamgbade
- Bouvé College of Health Sciences, Department of Pharmacy and Health System Sciences, Northeastern University, Boston, MA
| | - Tenes J. Paul
- Meyers Primary Care Institute and Division of Geriatric Medicine, University of Massachusetts Medical School, Worcester, MA
| | - Darleen M. Lessard
- Division of Epidemiology of Chronic Diseases, Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA
| | - David D. McManus
- Division of Cardiology, Department of Medicine, University of Massachusetts Medical School, Worcester, MA
| | - Robert H. Helm
- Evans Department of Medicine, Cardiovascular Medicine Section, Arrhythmia Service, Boston University School of Medicine, Boston, MA
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12
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Ding EY, CastañedaAvila M, Tran KV, Mehawej J, Filippaios A, Paul T, Otabil EM, Noorishirazi K, Han D, Saczynski JS, Barton B, Mazor KM, Chon K, McManus DD. Usability of a smartwatch for atrial fibrillation detection in older adults after stroke. Cardiovasc Digit Health J 2022; 3:126-135. [PMID: 35720675 PMCID: PMC9204791 DOI: 10.1016/j.cvdhj.2022.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background Smartwatches can be used for atrial fibrillation (AF) detection, but little is known about how older adults at risk for AF perceive their usability. Methods We employed a mixed-methods study design using data from the ongoing Pulsewatch study, a randomized clinical trial (NCT03761394) examining the accuracy of a smartwatch-smartphone app dyad (Samsung/Android) compared to usual care with a patch monitor (Cardea SOLO™ ECG System) for detection of AF among older stroke survivors. To be eligible to participate in Pulsewatch, participants needed to be at least 50 years of age, have had an ischemic stroke, and have no major contraindications to anticoagulation therapy should AF be detected. After 14 days of use, usability was measured by the System Usability Scale (SUS) and investigator-generated questions. Qualitative interviews were conducted, transcribed, and coded via thematic analysis. Results Ninety participants in the Pulsewatch trial were randomized to use a smartwatch-smartphone app dyad for 14 days (average age: 65 years, 41% female, 87% White), and 46% found it to be highly usable (SUS ≥68). In quantitative surveys, participants who used an assistive device (eg, wheelchair) and those with history of anxiety or depression were more likely to report anxiety associated with watch use. In qualitative interviews, study participants reported wanting a streamlined system that was more focused on rhythm monitoring and a smartwatch with a longer battery life. In-person training and support greatly improved their experience, and participants overwhelmingly preferred use of a smartwatch over traditional cardiac monitoring owing to its comfort, appearance, and convenience. Conclusion Older adults at high risk for AF who were randomized to use a smartwatch-app dyad for AF monitoring over 14 days found it to be usable for AF detection and preferred their use to the use of a patch monitor. However, participants reported that a simpler device interface and longer smartwatch battery life would increase the system's usability.
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Affiliation(s)
- Eric Y. Ding
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, Massachusetts
- Address reprint requests and correspondence: Mr Eric Y. Ding, University of Massachusetts Chan Medical School, 55 N Lake Ave, Worcester, MA 01655.
| | - Maira CastañedaAvila
- Department of Population and Quantitative Health Sciences at the University of Massachusetts Medical School, Worcester, Massachusetts
| | - Khanh-Van Tran
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, Massachusetts
| | - Jordy Mehawej
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, Massachusetts
| | - Andreas Filippaios
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, Massachusetts
| | - Tenes Paul
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, Massachusetts
| | - Edith Mensah Otabil
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, Massachusetts
| | - Kamran Noorishirazi
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, Massachusetts
| | - Dong Han
- Department of Biomedical Engineering, University of Connecticut, Storrs, Connecticut
| | - Jane S. Saczynski
- Department of Pharmacy and Health Systems Sciences, Northeastern University, Boston, Massachusetts
| | - Bruce Barton
- Department of Population and Quantitative Health Sciences at the University of Massachusetts Medical School, Worcester, Massachusetts
| | - Kathleen M. Mazor
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, Massachusetts
| | - Ki Chon
- Department of Biomedical Engineering, University of Connecticut, Storrs, Connecticut
| | - David D. McManus
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, Massachusetts
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13
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Duprey MS, Devlin JW, Griffith JL, Travison TG, Briesacher BA, Jones R, Saczynski JS, Schmitt EM, Gou Y, Marcantonio ER, Inouye SK. Association Between Perioperative Medication Use and Postoperative Delirium and Cognition in Older Adults Undergoing Elective Noncardiac Surgery. Anesth Analg 2022; 134:1154-1163. [PMID: 35202006 PMCID: PMC9124692 DOI: 10.1213/ane.0000000000005959] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [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] [Indexed: 12/19/2022]
Abstract
BACKGROUND Postoperative delirium is frequent in older adults and is associated with postoperative neurocognitive disorder (PND). Studies evaluating perioperative medication use and delirium have generally evaluated medications in aggregate and been poorly controlled; the association between perioperative medication use and PND remains unclear. We sought to evaluate the association between medication use and postoperative delirium and PND in older adults undergoing major elective surgery. METHODS This is a secondary analysis of a prospective cohort study of adults ≥70 years without dementia undergoing major elective surgery. Patients were interviewed preoperatively to determine home medication use. Postoperatively, daily hospital use of 7 different medication classes listed in guidelines as risk factors for delirium was collected; administration before delirium was verified. While hospitalized, patients were assessed daily for delirium using the Confusion Assessment Method and a validated chart review method. Cognition was evaluated preoperatively and 1 month after surgery using a neurocognitive battery. The association between prehospital medication use and postoperative delirium was assessed using a generalized linear model with a log link function, controlling for age, sex, type of surgery, Charlson comorbidity index, and baseline cognition. The association between daily postoperative medication use (when class exposure ≥5%) and time to delirium was assessed using time-varying Cox models adjusted for age, sex, surgery type, Charlson comorbidity index, Acute Physiology and Chronic Health Evaluation (APACHE)-II score, and baseline cognition. Mediation analysis was utilized to evaluate the association between medication use, delirium, and cognitive change from baseline to 1 month. RESULTS Among 560 patients enrolled, 134 (24%) developed delirium during hospitalization. The multivariable analyses revealed no significant association between prehospital benzodiazepine (relative risk [RR], 1.44; 95% confidence interval [CI], 0.85-2.44), beta-blocker (RR, 1.38; 95% CI, 0.94-2.05), NSAID (RR, 1.12; 95% CI, 0.77-1.62), opioid (RR, 1.22; 95% CI, 0.82-1.82), or statin (RR, 1.34; 95% CI, 0.92-1.95) exposure and delirium. Postoperative hospital benzodiazepine use (adjusted hazard ratio [aHR], 3.23; 95% CI, 2.10-4.99) was associated with greater delirium. Neither postoperative hospital antipsychotic (aHR, 1.48; 95% CI, 0.74-2.94) nor opioid (aHR, 0.82; 95% CI, 0.62-1.11) use before delirium was associated with delirium. Antipsychotic use (either presurgery or postsurgery) was associated with a 0.34 point (standard error, 0.16) decrease in general cognitive performance at 1 month through its effect on delirium (P = .03), despite no total effect being observed. CONCLUSIONS Administration of benzodiazepines to older adults hospitalized after major surgery is associated with increased postoperative delirium. Association between inhospital, postoperative medication use and cognition at 1 month, independent of delirium, was not detected.
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Affiliation(s)
| | - John W. Devlin
- Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston, MA
- Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - John L. Griffith
- Department of Health Sciences, Bouve College of Health Sciences, Northeastern University, Boston, MA
| | - Thomas G. Travison
- Harvard Medical School, Boston, MA
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
| | - Becky A. Briesacher
- Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston, MA
| | - Richard Jones
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
- Departments of Psychiatry and Human Behavior, Warren Alpert Medical School, Brown University, Providence, RI
| | - Jane S. Saczynski
- Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston, MA
| | - Eva M. Schmitt
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
| | - Yun Gou
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
| | - Edward R. Marcantonio
- Harvard Medical School, Boston, MA
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Sharon K. Inouye
- Harvard Medical School, Boston, MA
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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14
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Nuvvula S, Ding EY, Saleeba C, Shi Q, Wang Z, Kapoor A, Saczynski JS, Lubitz SA, Kovell LC, McKee MD, McManus DD. NExUS-Heart: Novel examinations using smart technologies for heart health-Data sharing from commercial wearable devices and telehealth engagement in participants with or at risk of atrial fibrillation. Cardiovasc Digit Health J 2022; 2:256-263. [PMID: 35265917 PMCID: PMC8890085 DOI: 10.1016/j.cvdhj.2021.08.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [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] [Indexed: 11/26/2022] Open
Abstract
Background Telemedicine and commercial wearable devices capable of detecting atrial fibrillation (AF) have revolutionized arrhythmia care during coronavirus disease 2019. However, not much is known about virtual patient-provider interactions or device sharing behaviors. Objective The purpose of this study was to characterize how participants with or at risk of AF are engaging with their providers in the context of telemedicine and using commercially wearable devices to manage their health. Methods We developed a survey to describe participant behaviors around telemedicine encounters and commercial wearable device use. The survey was distributed to participants diagnosed with AF or those at risk of AF (as determined by being at least 65 years old and having a CHA2DS2-VASc stroke risk score of >2) in the University of Massachusetts Memorial Health Care system. Results The survey was distributed to 23,530 patients, and there were 1222 (5.19%) participant responses. Among the participants, 327 (26.8%) had AF and 895 (73.2%) were at risk of AF. Neither device ownership nor device type use differed by AF status. After adjusting for covariates that may influence surveyed participant communication patterns, we found that participants with AF were more likely to share their wearable device-derived data with providers (adjusted odds ratio 1.87; 95% confidence interval 1.02-3.41). Rates of sharing physical activity or sleep data were low for both groups and did not differ by AF status. Conclusion Compared with participants at risk of developing AF, those with AF were more likely to share heart rate and rhythm data from their commercial wearable devices with providers. However, both groups had similar rates of sharing physical activity and sleep data, telemedicine engagement, and technology use and ownership.
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Affiliation(s)
- Sri Nuvvula
- Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Eric Y Ding
- Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Connor Saleeba
- Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Qiming Shi
- Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Ziyue Wang
- Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Alok Kapoor
- Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Jane S Saczynski
- Department of Pharmacy and Health Systems Sciences, Northeastern University, Boston, Massachusetts
| | - Steven A Lubitz
- Cardiac Arrhythmia Service and Cardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts
| | - Lara C Kovell
- Department of Cardiovascular Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - M Diane McKee
- Department of Family Medicine and Community Health, University of Massachusetts Medical School, Worcester, Massachusetts
| | - David D McManus
- Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
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15
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Mehawej J, Mishra A, Saczynski JS, Waring ME, Lessard D, Abu HO, La V, Tisminetzky M, Tran KV, Hariri E, Filippaios A, Paul T, Soni A, Wang W, Ding EY, Bamgbade BA, Mathew J, Kiefe C, Goldberg RJ, McManus DD. Online Health Information Seeking, Low AF-Related Quality of Life, and High Perceived Efficacy in Patient-Physician Interactions in Older Adults with Atrial Fibrillation. Cardiovascular Digital Health Journal 2022; 3:118-125. [PMID: 35720678 PMCID: PMC9204795 DOI: 10.1016/j.cvdhj.2022.03.001] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background Little is known about online health information–seeking behavior among older adults with atrial fibrillation (AF) and its association with self-reported outcomes. Objective To examine patient characteristics associated with online health information seeking and the association between information seeking and low AF-related quality of life and high perceived efficacy in patient-physician interaction. Methods We used data from the SAGE-AF (Systematic Assessment of Geriatric Elements in AF) study, which includes older participants aged ≥65 years with AF and a CHA2DS2-VASc risk score ≥2. To assess online health information seeking, participants who reported using the Internet were asked at baseline if they used the Internet to search for advice or information about their health in the past 4 weeks (not at all vs at least once). Atrial Fibrillation Effect on Quality of Life and Perceived Efficacy in Patient-Physician Interactions questionnaires were used to examine AF-related quality of life (QOL) and patient-reported confidence in physicians. Logistic regression models were used to examine demographic and clinical factors associated with online health information seeking and associations between information seeking and low AF-related QOL (AFEQT <80) and high perceived efficacy for patient-physician interactions (PEPPI ≥45). Results A total of 874 online participants (mean age 74.5 years, 51% male, 91% non-Hispanic White) were studied. Approximately 60% of participants sought health information online. Participants aged 74 years or older and those on anticoagulation were less likely, while those with a college degree were more likely, to seek online health information after adjusting for potential confounders. Participants who sought health information online, compared to those who did not, were significantly more likely to have a low AF-related QOL, but less likely to self-report confidence in patient-physician interaction (aOR = 1.56, 95% CI: 1.15–2.13; aOR = 0.68, 95% CI: 0.49–0.93, respectively). Conclusion Clinicians should consider barriers to patient-physician interaction in older adults who seek health information online, encourage shared decision-making, and provide patients with a list of online resources for AF in addition to disease education plans to help patients manage their health.
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16
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Sanghai SR, Liu W, Wang W, Rongali S, Orkaby AR, Saczynski JS, Rose AJ, Kapoor A, Li W, Yu H, McManus DD. Prevalence of Frailty and Associations with Oral Anticoagulant Prescribing in Atrial Fibrillation. J Gen Intern Med 2022; 37:730-736. [PMID: 33948795 PMCID: PMC8904680 DOI: 10.1007/s11606-021-06834-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [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: 12/06/2020] [Accepted: 04/14/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Frailty is often cited as a factor influencing oral anticoagulation (OAC) prescription in patients with non-valvular atrial fibrillation (NVAF). We sought to determine the prevalence of frailty and its association with OAC prescription in older veterans with NVAF. METHODS We used ICD-9 codes in Veterans Affairs (VA) records and Medicare claims data to identify patients with NVAF and CHA2DS2VASC ≥2 receiving care between February 2010 and September 2015. We examined rates of OAC prescription, further stratified by direct oral anticoagulant (DOAC) or vitamin K antagonist (VKA). Participants were characterized into 3 categories: non-frail, pre-frail, and frail based on a validated 30-item EHR-derived frailty index. We examined relations between frailty and OAC receipt; and frailty and type of OAC prescribed in regression models adjusted for factors related to OAC prescription. RESULTS Of 308,664 veterans with NVAF and a CHA2DS2VASC score ≥2, 121,839 (39%) were prescribed OAC (73% VKA). The mean age was 77.7 (9.6) years; CHA2DS2VASC and ATRIA scores were 4.6 (1.6) and 5.0 (2.9) respectively. Approximately a third (38%) were frail, another third (32%) were pre-frail, and the remainder were not frail. Veterans prescribed OAC were younger, had higher bleeding risk, and were less likely to be frail than participants not receiving OAC (all p's<0.001). After adjustment for factors associated with OAC use, pre-frail (OR: 0.89, 95% CI: 0.87-0.91) and frail (OR: 0.66, 95% CI: 0.64-0.68) veterans were significantly less likely to be prescribed OAC than non-frail veterans. Of those prescribed OAC, pre-frail (OR:1.27, 95% CI: 1.22-1.31) and frail (OR: 1.75, 95% CI: 1.67-1.83) veterans were significantly more likely than non-frail veterans to be prescribed a DOAC than a VKA. CONCLUSIONS There are high rates of frailty among older veterans with NVAF. Frailty using an EHR-derived index is associated with decreased OAC prescription.
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Affiliation(s)
- Saket R Sanghai
- Division of Cardiac Electrophysiology, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA.
| | - Weisong Liu
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Weijia Wang
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | | | - Ariela R Orkaby
- New England GRECC, VA Boston Health Care System, Boston, MA, USA
- Division of Aging, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jane S Saczynski
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
- Department of Pharmacy and Health System Sciences, Northeastern University, Boston, MA, USA
| | - Adam J Rose
- Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Alok Kapoor
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Wenjun Li
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Hong Yu
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
- University of Massachusetts, Lowell, MA, USA
- Edith Nourse Rogers Memorial VA Medical Center, Bedford, MA, USA
| | - David D McManus
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
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17
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Mehawej J, Saczynski JS, Kiefe CI, Abu HO, Tisminetzky M, Wang W, Bamgbade BA, Ding E, Lessard D, Otabil EM, Saleeba C, Goldberg RJ, McManus DD. Association between risk of obstructive sleep apnea and cognitive performance, frailty, and quality of life among older adults with atrial fibrillation. J Clin Sleep Med 2022; 18:469-475. [PMID: 34432629 PMCID: PMC8805012 DOI: 10.5664/jcsm.9622] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 08/16/2021] [Accepted: 08/18/2021] [Indexed: 02/03/2023]
Abstract
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 ≥ 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 = 1.67, 95% confidence interval: 1.08-2.56; adjusted odds ratio = 3.00, 95% confidence interval: 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 quality of life among patients with AF. CITATION Mehawej J, Saczynski JS, Kiefe CI, et al. Association between risk of obstructive sleep apnea and cognitive performance, frailty, and quality of life among older adults with atrial fibrillation. J Clin Sleep Med. 2022;18(2):469-475.
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Affiliation(s)
- Jordy Mehawej
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Jane S. Saczynski
- Department of Pharmacy and Health Systems Sciences, School of Pharmacy, Northeastern University, Boston, Massachusetts
| | - Catarina I. Kiefe
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Hawa O. Abu
- Department of Medicine, Saint Vincent Hospital, Worcester, Massachusetts
| | - Mayra Tisminetzky
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
- Division of Geriatrics, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Weijia Wang
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Benita A. Bamgbade
- Department of Pharmacy and Health Systems Sciences, School of Pharmacy, Northeastern University, Boston, Massachusetts
| | - Eric Ding
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Darleen Lessard
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Edith Mensah Otabil
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Connor Saleeba
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Robert J. Goldberg
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - David D. McManus
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
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18
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Briesacher BA, Olivieri‐Mui BL, Koethe B, Saczynski JS, Fick DM, Devlin JW, Marcantonio ER. Psychoactive medication therapy and delirium screening in skilled nursing facilities. J Am Geriatr Soc 2022; 70:1517-1524. [PMID: 35061246 PMCID: PMC9106820 DOI: 10.1111/jgs.17662] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 12/14/2021] [Accepted: 01/04/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND A positive delirium screen at skilled-nursing facility (SNF) admission can trigger a simultaneous diagnosis of Alzheimer's Disease or related dementia (AD/ADRD) and lead to psychoactive medication treatment despite a lack of evidence supporting use. METHODS This was a nationwide historical cohort study of 849,086 Medicare enrollees from 2011-2013 who were admitted to the SNF from a hospital without a history of dementia. Delirium was determined through positive Confusion Assessment Method screen and incident AD/ADRD through active diagnosis or claims. Cox proportional hazard models predicted the risk of receiving one of three psychoactive medications (i.e., antipsychotics, benzodiazepines, antiepileptics) within 7 days of SNF admission and within the entire SNF stay. RESULTS Of 849,086 newly-admitted SNF patients (62.6% female, mean age 78), 6.1% had delirium (of which 35.4% received an incident diagnosis of AD/ADRD); 12.6% received antipsychotics, 30.4% benzodiazepines, and 5.8% antiepileptics. Within 7 days of admission, patients with delirium and incident dementia were more likely to receive an antipsychotic (relative risk [RR] 3.09; 95% confidence interval [CI] 2.99 to 3.20), or a benzodiazepine (RR 1.23; 95% CI 1.19 to 1.27) than patients without either condition. By the end of the SNF stay, patients with both delirium and incident dementia were more likely to receive an antipsychotic (RR 3.04; 95% CI 2.95 to 3.14) and benzodiazepine (RR 1.32; 95% CI 1.29 to 1.36) than patients without either condition. CONCLUSION In this historical cohort, a positive delirium screen was associated with a higher risk of receiving psychoactive medication within 7 days of SNF admission, particularly in patients with an incident AD/ADRD diagnosis. Future research should examine strategies to reduce inappropriate psychoactive medication prescribing in older adults admitted with delirium to SNFs.
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Affiliation(s)
- Becky A. Briesacher
- Bouvé College of Health Sciences, School of Pharmacy Northeastern University Boston Massachusetts USA
| | - Brianne L. Olivieri‐Mui
- Hebrew SeniorLife The Marcus Institute for Aging Research, Harvard Medical School Boston Massachusetts USA
| | - Benjamin Koethe
- Bouvé College of Health Sciences, School of Pharmacy Northeastern University Boston Massachusetts USA
| | - Jane S. Saczynski
- Bouvé College of Health Sciences, School of Pharmacy Northeastern University Boston Massachusetts USA
| | - Donna Marie Fick
- Center of Geriatric Nursing Excellence Penn State College of Nursing University Park Pennsylvania USA
| | - John W. Devlin
- Bouvé College of Health Sciences, School of Pharmacy Northeastern University Boston Massachusetts USA
| | - Edward R. Marcantonio
- Harvard Medical School, Divisions of General Medicine and Gerontology Beth Israel Deaconess Medical Center Boston Massachusetts USA
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19
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Mailhot T, Saczynski JS, Malyuta Y, Inouye SK, Darling C. An Emergency Department Delirium Screening and Management Initiative: The Development and Refinement of the SCREENED-ED Intervention. J Gerontol Nurs 2021; 47:13-17. [PMID: 34846261 DOI: 10.3928/00989134-20211109-03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The current article describes an intervention aimed at emergency department (ED) nurses and physicians that was designed to address the challenges of managing delirium in the ED environment. The intervention development process followed the Medical Research Council principles paired with a user-centered design perspective. Expert clinicians and nursing staff were involved in the development process. As a result, the SCREENED-ED intervention includes four major components: screening for delirium, informing providers, an acronym (ALTERED), and documentation in the electronic health record. The acronym "ALTERED" includes seven key elements of delirium management that were considered the most evidence-based, relevant, and practical for the ED. Nurses are at the frontline of delirium recognition and management and the SCREENED-ED intervention with the ALTERED acronym holds the potential to improve nursing care in this complex clinical setting. [Journal of Gerontological Nursing, 47(12), 13-17.].
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20
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Ding EY, Mehawej J, Abu H, Lessard D, Saczynski JS, McManus DD, Kiefe CI, Goldberg RJ. Cardiovascular Health Metrics in Patients Hospitalized with an Acute Coronary Syndrome. Am J Med 2021; 134:1396-1402.e1. [PMID: 34273284 PMCID: PMC8605989 DOI: 10.1016/j.amjmed.2021.06.016] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 06/03/2021] [Accepted: 06/08/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND The Life's Simple 7 (LS7) is a guiding metric for primordial/primary prevention of cardiovascular disease. However, little is known about the prevalence and distribution of LS7 metrics in patients with an acute coronary syndrome at the time of hospitalization. METHODS Data were obtained from patients hospitalized for an acute coronary syndrome at 6 hospitals in Central Massachusetts and Georgia (2011-2013). The LS7 assessed patient's smoking, diet, and physical activity based on self-reported measures, and patients' body mass index, blood pressure, and serum cholesterol and glucose levels were abstracted from medical records. All items were operationalized into 3 categories: poor (0), intermediate (1), or ideal (2). A total summary cardiovascular health score (0-14) was obtained and categorized into tertiles (0-5, 6-7, and 8-14). RESULTS The average age of study participants (n = 1110) was 59.6 years and 35% were women. Cardiovascular health scores ranged from 0-12 (mean = 6.2). Patients with higher scores were older, white, had lower burden of comorbidities, had fewer symptoms of anxiety, depression, and stress, better quality of life, more social support, and greater healthcare activation. One-third of patients had only 1 ideal cardiovascular health measure, less than 1% had 5, and no participant had more than 5 ideal factors. CONCLUSIONS Our results indicate that patients with acute coronary syndrome have poor cardiovascular health. Sociodemographic, clinical, and psychosocial characteristics differed across cardiovascular health groups. These findings highlight potential areas for educational and therapeutic interventions to reduce the risk of cardiovascular disease and promote cardiovascular health in adult men and women.
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Affiliation(s)
- Eric Y Ding
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester; Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester.
| | - Jordy Mehawej
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester
| | - Hawa Abu
- Department of Medicine, St. Vincent's Hospital, Worcester, Mass
| | - Darleen Lessard
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester
| | - Jane S Saczynski
- Department of Pharmacy and Health Systems Sciences, Northeastern University, Boston, Mass
| | - David D McManus
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester; Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester
| | - Catarina I Kiefe
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester
| | - Robert J Goldberg
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester
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21
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Bamgbade BA, McManus DD, Helm R, Mehawej J, Gurwitz JH, Mailhot T, Abu HO, Goldberg R, Wang Z, Tisminetzky M, Pierre‐Louis IC, Saczynski JS. Differences in Perceived and Predicted Bleeding Risk in Older Adults With Atrial Fibrillation: The SAGE-AF Study. J Am Heart Assoc 2021; 10:e019979. [PMID: 34398677 PMCID: PMC8649256 DOI: 10.1161/jaha.120.019979] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 05/18/2021] [Indexed: 11/16/2022]
Abstract
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 ≥65 years with atrial fibrillation, a CHA2DS2-VASc risk score ≥2 and who were on oral anticoagulant therapy, we compared patients' 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.
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Affiliation(s)
- Benita A. Bamgbade
- Department of Pharmacy and Health System SciencesNortheastern UniversityBostonMA
| | - David D. McManus
- Cardiology DivisionDepartment of MedicineUniversity of Massachusetts Medical SchoolWorcesterMA
- Department of Population and Quantitative Health SciencesUniversity of Massachusetts Medical SchoolWorcesterMA
| | - Robert Helm
- Department of MedicineCardiovascular MedicineBoston University School of MedicineBostonMA
| | - Jordy Mehawej
- Cardiology DivisionDepartment of MedicineUniversity of Massachusetts Medical SchoolWorcesterMA
| | - Jerry H. Gurwitz
- Department of Population and Quantitative Health SciencesUniversity of Massachusetts Medical SchoolWorcesterMA
- Meyers Primary Care InstituteWorcesterMA
- Division of Geriatric MedicineUniversity of Massachusetts Medical SchoolWorcesterMA
| | - Tanya Mailhot
- Faculty of NursingUniversite de MontrealMontrealQuebecCanada
- Montreal Heart Institute Research CenterMontrealQuebecCanada
| | - Hawa O. Abu
- Cardiology DivisionDepartment of MedicineUniversity of Massachusetts Medical SchoolWorcesterMA
| | - Robert Goldberg
- Department of Population and Quantitative Health SciencesUniversity of Massachusetts Medical SchoolWorcesterMA
| | - Ziyue Wang
- Department of Population and Quantitative Health SciencesUniversity of Massachusetts Medical SchoolWorcesterMA
| | - Mayra Tisminetzky
- Department of Population and Quantitative Health SciencesUniversity of Massachusetts Medical SchoolWorcesterMA
- Division of Geriatric MedicineUniversity of Massachusetts Medical SchoolWorcesterMA
| | | | - Jane S. Saczynski
- Department of Pharmacy and Health System SciencesNortheastern UniversityBostonMA
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22
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Duprey MS, Dijkstra-Kersten SMA, Zaal IJ, Briesacher BA, Saczynski JS, Griffith JL, Devlin JW, Slooter AJC. Opioid Use Increases the Risk of Delirium in Critically Ill Adults Independently of Pain. Am J Respir Crit Care Med 2021; 204:566-572. [PMID: 33835902 PMCID: PMC8491270 DOI: 10.1164/rccm.202010-3794oc] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [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: 10/04/2020] [Accepted: 04/09/2021] [Indexed: 11/16/2022] Open
Abstract
Rationale: It is unclear whether opioid use increases the risk of ICU delirium. Prior studies have not accounted for confounding, including daily severity of illness, pain, and competing events that may preclude delirium detection.Objectives: To evaluate the association between ICU opioid exposure, opioid dose, and delirium occurrence.Methods: In consecutive adults admitted for more than 24 hours to the ICU, daily mental status was classified as awake without delirium, delirium, or unarousable. A first-order Markov model with multinomial logistic regression analysis considered four possible next-day outcomes (i.e., awake without delirium, delirium, unarousable, and ICU discharge or death) and 11 delirium-related covariables (baseline: admission type, age, sex, Acute Physiology and Chronic Health Evaluation IV score, and Charlson comorbidity score; daily: ICU day, modified Sequential Organ Failure Assessment, ventilation use, benzodiazepine use, and severe pain). This model was used to quantify the association between opioid use, opioid dose, and delirium occurrence the next day.Measurements and Main Results: The 4,075 adults had 26,250 ICU days; an opioid was administered on 57.0% (n = 14,975), severe pain occurred on 7.0% (n = 1,829), and delirium occurred on 23.5% (n = 6,176). Severe pain was inversely associated with a transition to delirium (odds ratio [OR] 0.72; 95% confidence interval [CI], 0.53-0.97). Any opioid administration in awake patients without delirium was associated with an increased risk for delirium the next day [OR, 1.45; 95% CI, 1.24-1.69]. Each daily 10-mg intravenous morphine-equivalent dose was associated with a 2.4% increased risk for delirium the next day.Conclusions: The receipt of an opioid in the ICU increases the odds of transitioning to delirium in a dose-dependent fashion.
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Affiliation(s)
| | - Sandra M. A. Dijkstra-Kersten
- Department of Intensive Care Medicine, and
- Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Irene J. Zaal
- Department of Intensive Care Medicine, and
- Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | | | | | - John L. Griffith
- Department of Health Sciences, Bouve College of Health Sciences, Northeastern University, Boston, Massachusetts
| | - John W. Devlin
- Department of Pharmacy and Health Systems Sciences and
- Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, Boston, Massachusetts; and
| | - Arjen J. C. Slooter
- Department of Intensive Care Medicine, and
- Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- Department of Neurology, University Ziekenhuis Brussel and Vrije University, Brussels, Belgium
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23
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Forrester SN, McManus DD, Saczynski JS, Pierre-Louis IC, Bamgbade BA, Kiefe CI. 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. EClinicalMedicine 2021; 39:101060. [PMID: 34386761 PMCID: PMC8342899 DOI: 10.1016/j.eclinm.2021.101060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 07/12/2021] [Accepted: 07/15/2021] [Indexed: 11/05/2022] Open
Abstract
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.
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Affiliation(s)
- Sarah N. Forrester
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, 368 Plantation Street AS6-1075, Worcester, MA 01605, United States
- Corresponding author.
| | - David D. McManus
- Division of Cardiovascular Medicine, University of Massachusetts Medical School, Worcester, MA, United States
| | - Jane S. Saczynski
- Department of Pharmacy and Health System Sciences, Northeastern University, Boston MA, United States
| | - Isabelle C. Pierre-Louis
- Department of Pharmacy and Health System Sciences, Northeastern University, Boston MA, United States
| | - Benita A. Bamgbade
- Department of Pharmacy and Health System Sciences, Northeastern University, Boston MA, United States
| | - Catarina I. Kiefe
- Department of Pharmacy and Health System Sciences, Northeastern University, Boston MA, United States
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24
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Dickson EL, Ding EY, Saczynski JS, Han D, Moonis M, Fitzgibbons TP, Barton B, Chon K, McManus DD. Smartwatch monitoring for atrial fibrillation after stroke—The Pulsewatch Study: Protocol for a multiphase randomized controlled trial. Cardiovascular Digital Health Journal 2021; 2:231-241. [PMID: 35265913 PMCID: PMC8890084 DOI: 10.1016/j.cvdhj.2021.07.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background Atrial fibrillation (AF) is a common heart rhythm disorder that elevates stroke risk. Stroke survivors undergo routine heart rhythm monitoring for AF. Smartwatches are capable of AF detection and potentially can replace traditional cardiac monitoring in stroke patients. Objective The goal of Pulsewatch is to assess the accuracy, usability, and adherence of a smartwatch-based AF detection system in stroke patients. Methods The study will consist of two parts. Part I will have 6 focus groups with stroke patients, caretakers, and physicians, and a Hack-a-thon, to inform development of the Pulsewatch system. Part II is a randomized clinical trial with 2 phases designed to assess the accuracy and usability in the first phase (14 days) and adherence in the second phase (30 days). Participants will be randomized in a 3:1 ratio (intervention to control) for the first phase, and both arms will receive gold-standard electrocardiographic (ECG) monitoring. The intervention group additionally will receive a smartphone/smartwatch dyad with the Pulsewatch applications. Upon completion of 14 days, participants will be re-randomized in a 1:1 ratio. The intervention group will receive the Pulsewatch system and a handheld ECG device, while the control group will be passively monitored. Participants will complete questionnaires at enrollment and at 14- and 44-day follow-up visits to assess various psychosocial measures and health behaviors. Results Part I was completed in August 2019. Enrollment for Part II began September 2019, with expected completion by the end of 2021. Conclusion Pulsewatch aims to demonstrate that a smartwatch can be accurate for real-time AF detection, and that older stroke patients will find the system usable and will adhere to monitoring.
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25
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Hajduk AM, Saczynski JS, Tsang S, Geda ME, Dodson JA, Ouellet GM, Goldberg RJ, Chaudhry SI. Presentation, Treatment, and Outcomes of Older Adults Hospitalized for Acute Myocardial Infarction According to Cognitive Status: The SILVER-AMI Study. Am J Med 2021; 134:910-917. [PMID: 33737057 PMCID: PMC8243828 DOI: 10.1016/j.amjmed.2021.03.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 02/12/2021] [Accepted: 03/01/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND While survival after acute myocardial infarction has improved substantially, older adults remain at heightened risk for hospital readmissions and death. Evidence for the role of cognitive impairment in older myocardial infarction survivors' risk for these outcomes is limited. METHODS 3041 patients aged ≥75 years hospitalized with acute myocardial infarction (mean age 82 ± 5 years, 56% male) recruited from 94 US hospitals. Cognition was assessed using the Telephone Interview for Cognitive Status; scores of <27 and <22 indicated mild and moderate/severe impairment, respectively. Readmissions and death at 6 months post-discharge were ascertained via participant report and medical record review. Associations between cognition and outcomes were evaluated with multivariable-adjusted logistic regression. RESULTS Mild and moderate/severe cognitive impairment were present in 11% and 6% of the cohort, respectively. Readmission and death at 6 months occurred in 41% and 9% of participants, respectively. Mild and moderate/severe cognitive impairment were associated with increased risk of readmission (odds ratio [OR] 1.36; 95% confidence interval [CI], 1.08-1.72 and OR 1.58; 95% CI, 1.18-2.12, respectively) and death (OR 2.19; 95% CI, 1.54-3.11 and OR 3.82; 95% CI, 2.63-5.56, respectively) in unadjusted analyses. Significant associations between moderate/severe cognitive impairment and death (OR 1.69; 95% CI, 1.10-2.59) persisted after adjustment for demographics, myocardial infarction characteristics, comorbidity burden, functional status, and depression, but not for readmissions. CONCLUSIONS Moderate-to-severe cognitive impairment is associated with heightened risk of death in older acute myocardial infarction patients in the months after hospitalization, but not with readmission. Routine cognitive screening may identify older myocardial infarction survivors at risk for poor outcomes who may benefit from closer oversight and support in the post-discharge period.
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Affiliation(s)
- Alexandra M Hajduk
- Department of Internal Medicine, Yale School of Medicine, New Haven, Conn.
| | - Jane S Saczynski
- Department of Pharmacy and Health Systems Science, Northeastern School of Pharmacy, Boston, Mass
| | - Sui Tsang
- Department of Internal Medicine, Yale School of Medicine, New Haven, Conn
| | - Mary E Geda
- Department of Internal Medicine, Yale School of Medicine, New Haven, Conn
| | - John A Dodson
- Leon H. Charney Division of Cardiology, Department of Medicine; Division of Healthcare Delivery Science, Department of Population Health, New York University School of Medicine, New York, NY
| | - Gregory M Ouellet
- Department of Internal Medicine, Yale School of Medicine, New Haven, Conn
| | - Robert J Goldberg
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester
| | - Sarwat I Chaudhry
- Department of Internal Medicine, Yale School of Medicine, New Haven, Conn
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Wang W, Lessard D, Saczynski JS, Goldberg RJ, Mehawej J, Gracia E, McManus DD. Prognostic value of geriatric conditions for death and bleeding in older patients with atrial fibrillation. Int J Cardiol Heart Vasc 2021; 33:100739. [PMID: 33728372 PMCID: PMC7935705 DOI: 10.1016/j.ijcha.2021.100739] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 01/20/2021] [Accepted: 02/08/2021] [Indexed: 11/24/2022]
Abstract
Background Geriatric conditions, such as frailty and cognitive impairment, are prevalent in older patients with atrial fibrillation (AF). We examined the prognostic value of geriatric conditions for predicting 1-year mortality and bleeding events in these patients. Methods SAGE (Systematic Assessment of Geriatric Elements)-AF study is a multicenter cohort study which enrolled individuals (mean age 75 years, 48% women, 86% taking oral anticoagulation) 65 years and older with AF and CHA2DS2 -VASc score of 2 or higher from clinics in Massachusetts and Georgia, USA between 2016 and 2018. A six-component geriatric assessment included validated measures of frailty, cognitive function, social support, depressive symptoms, vision, and hearing was performed at baseline. Study endpoints included all-cause mortality and clinically relevant bleeding. Results At 1 year, 1,097 (96.5%) individuals attended the follow up visit, 44 (3.9%) had died, and 56 (5.1%) had clinically relevant bleeding. After adjustment for demographic and clinical factors, social isolation (odds ratio [OR] 1.69, 95% confidence interval [CI]: 1.01–2.84), depression (OR 1.94, 95% CI: 1.28–2.95) and frailty (OR 2.55, 95% CI: 1.55–4.19) were significantly associated with the composite endpoint of death or clinically relevant bleeding. After multivariable adjustment, depression (OR 1.79, 95% CI 1.09–2.93) and frailty (OR 2.83, 95% CI 1.55–5.17) were significantly associated with clinically relevant bleeding. Conclusions Social isolation, depression, and frailty were prognostic of dying or experiencing clinically relevant bleeding during the coming year in older men and women with AF. Assessing geriatric impairments merits consideration in the care of these patients.
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Affiliation(s)
- Weijia Wang
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Darleen Lessard
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Jane S Saczynski
- Department of Pharmacy and Health System Sciences, Northeastern University, Boston, MA, USA
| | - Robert J Goldberg
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Jordy Mehawej
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Ely Gracia
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - David D McManus
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA.,Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
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Briesacher BA, Koethe B, Olivieri-Mui B, Saczynski JS, Fick DM, Devlin JW, Marcantonio ER. Association of Positive Delirium Screening with Incident Dementia in Skilled Nursing Facilities. J Am Geriatr Soc 2020; 68:2931-2936. [PMID: 32965034 PMCID: PMC8114416 DOI: 10.1111/jgs.16830] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [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: 04/29/2020] [Revised: 07/27/2020] [Accepted: 08/11/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND OBJECTIVE Early detection of delirium in skilled nursing facilities (SNFs) is a priority. The extent to which delirium screening leads to a potentially inappropriate diagnosis of Alzheimer's disease and related dementia (ADRD) is unknown. DESIGN Nationwide retrospective cohort study from 2011 to 2013. SETTING An SNF. PARTICIPANTS A total of 1,175,550 Medicare enrollees who entered the SNF from a hospital and had no prior diagnosis of dementia. EXPOSURE A positive screen for delirium using the validated Confusion Assessment Method (CAM), performed as part of the federally mandated Minimum Data Set (MDS) assessment. MEASUREMENTS Incident all-cause dementia, ascertained through International Classification of Diseases, Ninth Revision (ICD-9), diagnosis in Medicare claims or active diagnoses in MDS. RESULTS Positive screening for delirium was identified in 7.7% of cases (n = 90,449), and most occurred within the first 7 days of SNF admission (62.5%). The overall incidence of ADRD was 6.3% (n = 73,542). Nearly all new diagnoses of ADRD (93.5%) occurred within the first 30 days of SNF admission. Patients who screened CAM positive for delirium had a nearly threefold increased risk of receiving an incident ADRD diagnosis on the same day (hazard ratio (HR) = 2.63; 95% confidence interval (CI) = 1.50-4.63). Among patients who screened CAM positive for delirium, those who were cognitively intact or had mild cognitive impairments were, on average, six times more likely to receive an incident ADRD diagnosis (HR = 6.64; 95% CI = 1.76-25.0) relative to those testing CAM negative. CONCLUSION AND RELEVANCE Among older adults not previously diagnosed with dementia, a positive screen for delirium was significantly associated with higher risk of ADRD diagnosis after admission to a SNF. This risk was highest for patients in the first days of their stay and with the least cognitive impairment, suggesting that the ADRD diagnosis was potentially inappropriate.
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Affiliation(s)
- Becky A. Briesacher
- Bouvé College of Health Sciences, School of Pharmacy, Northeastern University, Boston, Massachusetts
| | - Benjamin Koethe
- Bouvé College of Health Sciences, School of Pharmacy, Northeastern University, Boston, Massachusetts
| | - Brianne Olivieri-Mui
- Hebrew SeniorLife, The Marcus Institute for Aging Research, Harvard Medical School, Boston, Massachusetts
| | - Jane S. Saczynski
- Bouvé College of Health Sciences, School of Pharmacy, Northeastern University, Boston, Massachusetts
| | - Donna Marie Fick
- Penn State College of Nursing, Center of Geriatric Nursing Excellence, University Park, Pennsylvania
| | - John W. Devlin
- Bouvé College of Health Sciences, School of Pharmacy, Northeastern University, Boston, Massachusetts
| | - Edward R. Marcantonio
- Divisions of General Medicine and Gerontology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Mailhot T, McManus DD, Waring ME, Lessard D, Goldberg R, Bamgbade BA, Saczynski JS. Frailty, Cognitive Impairment, and Anticoagulation Among Older Adults with Nonvalvular Atrial Fibrillation. J Am Geriatr Soc 2020; 68:2778-2786. [PMID: 32780497 PMCID: PMC8567309 DOI: 10.1111/jgs.16756] [Citation(s) in RCA: 22] [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] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 07/07/2020] [Accepted: 07/08/2020] [Indexed: 07/21/2023]
Abstract
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.
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Affiliation(s)
- Tanya Mailhot
- Department of Pharmacy and Health System Sciences, Northeastern University, Boston, MA
| | - David D. McManus
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Molly E. Waring
- Department of Allied Health Sciences, University of Connecticut, Storrs, CT, USA
| | - Darleen Lessard
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Robert Goldberg
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Benita A. Bamgbade
- Department of Pharmacy and Health System Sciences, Northeastern University, Boston, MA
| | - Jane S. Saczynski
- Department of Pharmacy and Health System Sciences, Northeastern University, Boston, MA
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Yu-Wei Lu D, Reid DJ, Saczynski JS, Woolley AB. Evaluating patient knowledge and use of medication disposal in a Chinatown community pharmacy. J Am Pharm Assoc (2003) 2020; 61:e85-e93. [PMID: 33160870 DOI: 10.1016/j.japh.2020.10.006] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 09/29/2020] [Accepted: 10/07/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Drug take-back programs (TBPs) provide the opportunity to safely dispose of unused or expired medications (UEMs), potentially reducing the risk of environmental harm and morbidity. Data on patient perceptions and participation are limited, especially in underserved Asian populations. OBJECTIVE This study aimed to evaluate medication disposal perceptions and behaviors through a free mail-in medication disposal program among patients in a Chinatown community pharmacy. METHODS An institutional review board-approved Web-based survey was developed in English and Mandarin. Student pharmacists tabled at a Chinatown community pharmacy in Boston, Massachusetts. The patients were educated about safe medication disposal practices and invited to take the anonymous survey assessing medication disposal needs, practices, and beliefs accessed in person by using a quick response code. On survey completion, the patients were offered a disposal envelope. Envelope tracking numbers were used to evaluate medication disposal over a 9-month follow-up period. RESULTS Sixty-two patients of Asian descent completed the survey, and 42 (67.7%) accepted an envelope. Forty-seven patients (75.8%) reported having access to UEMs. More than half indicated that TBPs were important to alleviate the risk of medication and environmental consequences despite low previous use (6.5%). Most patients felt more aware of TBPs (72.6%), an increased sense of the importance of TBPs (74.2%), and intent to participate in TBPs (69.4%), including using the envelope (75.8%). Three (4.8%) patients disposed of medications using the study-provided envelope during the 9-month follow-up. CONCLUSION Patient education about TBPs and their importance may be effective in increasing TBP awareness in a population with low TBP use. Free disposal envelopes did not seem to be highly used within 9 months of receipt despite interest and access to UEMs. Future research should continue offering programs at no charge, evaluating barriers to free TBP use, and implementing follow-up procedures to increase envelope use.
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Trymbulak K, Ding E, Marino F, Wang Z, Saczynski JS. Mobile health assessments of geriatric elements in older patients with atrial fibrillation: The Mobile SAGE-AF Study (M-SAGE). Cardiovasc Digit Health J 2020; 1:123-129. [PMID: 35265884 PMCID: PMC8890350 DOI: 10.1016/j.cvdhj.2020.11.002] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Background Geriatric conditions (eg, cognitive impairment, frailty) are increasingly recognized for their impact on clinical and quality-of-life outcomes in older patients with cardiovascular disease, but are not systematically assessed in the context of clinical visits owing to time constraints. Objective To examine feasibility of remote monitoring of the physical, cognitive, and psychosocial status of older adults with atrial fibrillation (AF) via a novel smartphone app over 6 months. Methods Forty participants with AF and eligible for anticoagulation therapy (CHA2DS2VASc ≥2) enrolled in an ongoing cohort study participated in a mobile health pilot study. A 6-component geriatric assessment, including validated measures of frailty, cognitive function, social support, depressive symptoms, vision, and hearing, was deployed via a smartphone app and 6-minute walk test was completed using a Fitbit. Adherence to mobile assessments was examined over 6 months. Results Participants were an average of 71 years old (range 65-86 years) and 38% were women. At 1 month, 75% (30/40) of participants completed the app-based geriatric assessment and 63% (25/40) completed the 6-minute walk test. At 6 months, 52% (15/29) completed the geriatric assessment and 28% (8/29) completed the walk test. There were no differences in demographic, clinical, or psychosocial factors between participants who completed the surveys at 6 months and those who did not. Participants, on average, required less than 10 minutes of telephone support over the 6-month period. Conclusion It is feasible, among smartphone users, to use a mobile health app and wearable activity monitor to conduct serial geriatric assessments in older patients with AF for up to 6 months.
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Affiliation(s)
- Katherine Trymbulak
- Frank H. Netter M.D. School of Medicine at Quinnipiac University, North Haven, Connecticut
- Address reprint requests and correspondence: Ms Katherine Trymbulak, Frank H. Netter M.D. School of Medicine at Quinnipiac University, 370 Bassett Rd, North Haven, CT 06473.
| | - Eric Ding
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Francesca Marino
- Center for Clinical Investigation, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Ziyue Wang
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Jane S. Saczynski
- Department of Pharmacy and Health System Sciences, Northeastern University, Boston, Massachusetts
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Abu HO, Saczynski JS, Mehawej J, Tisminetzky M, Kiefe CI, Goldberg RJ, McManus DD. Clinically Meaningful Change in Quality of Life and Associated Factors Among Older Patients With Atrial Fibrillation. J Am Heart Assoc 2020; 9:e016651. [PMID: 32875941 PMCID: PMC7726984 DOI: 10.1161/jaha.120.016651] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Background Among older patients with atrial fibrillation, there are limited data examining clinically meaningful changes in quality of life (QoL). We examined the extent of, and factors associated with, clinically meaningful change in QoL over 1‐year among older adults with atrial fibrillation. Methods and Results Patients from cardiology, electrophysiology, and primary care clinics in Massachusetts and Georgia were enrolled in a cohort study (2015–2018). The Atrial Fibrillation Effect on Quality‐of‐Life questionnaire was used to assess overall QoL and across 3 subscales: symptoms, daily activities, and treatment concern. Clinically meaningful change in QoL (ie, difference between 1‐year and baseline QoL score) was categorized as either a decline (≤−5.0 points), no clinically meaningful change (−5.0 to +5.0 points), or an increase (≥+5.0 points). Ordinal logistic models were used to examine factors associated with QoL changes. Participants (n=1097) were on average 75 years old, 48% were women, and 87% White. Approximately 40% experienced a clinically meaningful increase in QoL and 1 in every 5 patients experienced a decline in QoL. After multivariable adjustment, women, non‐Whites, those who reported depressive and anxiety symptoms, fair/poor self‐rated health, low social support, heart failure, or diabetes mellitus experienced clinically meaningful declines in QoL. Conclusions These findings provide insights to the magnitude of, and factors associated with, clinically meaningful change in QoL among older patients with atrial fibrillation. Assessment of comorbidities and psychosocial factors may help identify patients at high risk for declining QoL and those who require additional surveillance to maximize important clinical and patient‐centered outcomes.
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Affiliation(s)
- Hawa O. Abu
- Division of Cardiovascular MedicineDepartment of MedicineUniversity of Massachusetts Medical SchoolWorcesterMA
| | - Jane S. Saczynski
- Department of Pharmacy and Health Systems SciencesSchool of PharmacyNorth Eastern UniversityBostonMA
| | - Jordy Mehawej
- Division of Cardiovascular MedicineDepartment of MedicineUniversity of Massachusetts Medical SchoolWorcesterMA
| | - Mayra Tisminetzky
- Division of Geriatrics and Meyers Primary Care InstituteDepartment of MedicineUniversity of Massachusetts Medical SchoolWorcesterMA
- Department of Population and Quantitative Health SciencesUniversity of Massachusetts Medical SchoolWorcesterMA
| | - Catarina I. Kiefe
- Department of Population and Quantitative Health SciencesUniversity of Massachusetts Medical SchoolWorcesterMA
| | - Robert J. Goldberg
- Department of Population and Quantitative Health SciencesUniversity of Massachusetts Medical SchoolWorcesterMA
| | - David D. McManus
- Division of Cardiovascular MedicineDepartment of MedicineUniversity of Massachusetts Medical SchoolWorcesterMA
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Abu HO, Saczynski JS, Ware J, Mehawej J, Paul T, Awad H, Bamgbade BA, Pierre-Louis IC, Tisminetzky M, Kiefe CI, Goldberg RJ, McManus DD. Impact of comorbid conditions on disease-specific quality of life in older men and women with atrial fibrillation. Qual Life Res 2020; 29:3285-3296. [PMID: 32656722 DOI: 10.1007/s11136-020-02578-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [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] [Accepted: 07/02/2020] [Indexed: 02/08/2023]
Abstract
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 ≥ 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 < 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' 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.
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Affiliation(s)
- Hawa O Abu
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA, 01655, USA.
| | - Jane S Saczynski
- Department of Pharmacy and Health Systems Sciences, School of Pharmacy, Northeastern University, Boston, MA, USA
| | - John Ware
- John Ware Research Group, Watertown, MA, USA
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Jordy Mehawej
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA, 01655, USA
| | - Tenes Paul
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA, 01655, USA
| | - Hamza Awad
- Departments of Community Medicine and Internal Medicine, Mercer University School of Medicine, Macon, GA, USA
| | - Benita A Bamgbade
- Department of Pharmacy and Health Systems Sciences, School of Pharmacy, Northeastern University, Boston, MA, USA
| | - Isabelle C Pierre-Louis
- Department of Pharmacy and Health Systems Sciences, School of Pharmacy, Northeastern University, Boston, MA, USA
| | - Mayra Tisminetzky
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
- Division of Geriatrics, Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Catarina I Kiefe
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Robert J Goldberg
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - David D McManus
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA, 01655, USA
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Duprey MS, van den Boogaard M, van der Hoeven JG, Pickkers P, Briesacher BA, Saczynski JS, Griffith JL, Devlin JW. Association between incident delirium and 28- and 90-day mortality in critically ill adults: a secondary analysis. Crit Care 2020; 24:161. [PMID: 32312288 PMCID: PMC7171767 DOI: 10.1186/s13054-020-02879-6] [Citation(s) in RCA: 21] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 04/06/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND While delirium prevalence and duration are each associated with increased 30-day, 6-month, and 1-year mortality, the association between incident ICU delirium and mortality remains unclear. We evaluated the association between both incident ICU delirium and days spent with delirium in the 28 days after ICU admission and mortality within 28 and 90 days. METHODS Secondary cohort analysis of a randomized, double-blind, placebo-controlled trial conducted among 1495 delirium-free, critically ill adults in 14 Dutch ICUs with an expected ICU stay ≥2 days where all delirium assessments were completed. In the 28 days after ICU admission, patients were evaluated for delirium and coma 3x daily; each day was coded as a delirium day [≥1 positive Confusion Assessment Method for the ICU (CAM-ICU)], a coma day [no delirium and ≥ 1 Richmond Agitation Sedation Scale (RASS) score ≤ - 4], or neither. Four Cox-regression models were constructed for 28-day mortality and 90-day mortality; each accounted for potential confounders (i.e., age, APACHE-II score, sepsis, use of mechanical ventilation, ICU length of stay, and haloperidol dose) and: 1) delirium occurrence, 2) days spent with delirium, 3) days spent in coma, and 4) days spent with delirium and/or coma. RESULTS Among the 1495 patients, 28 day mortality was 17% and 90 day mortality was 21%. Neither incident delirium (28 day mortality hazard ratio [HR] = 1.02, 95%CI = 0.75-1.39; 90 day mortality HR = 1.05, 95%CI = 0.79-1.38) nor days spent with delirium (28 day mortality HR = 1.00, 95%CI = 0.95-1.05; 90 day mortality HR = 1.02, 95%CI = 0.98-1.07) were significantly associated with mortality. However, both days spent with coma (28 day mortality HR = 1.05, 95%CI = 1.02-1.08; 90 day mortality HR = 1.05, 95%CI = 1.02-1.08) and days spent with delirium or coma (28 day mortality HR = 1.03, 95%CI = 1.00-1.05; 90 day mortality HR = 1.03, 95%CI = 1.01-1.06) were significantly associated with mortality. CONCLUSIONS This analysis suggests neither incident delirium nor days spent with delirium are associated with short-term mortality after ICU admission. TRIAL REGISTRATION ClinicalTrials.gov, Identifier NCT01785290 Registered 7 February 2013.
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Affiliation(s)
- Matthew S Duprey
- Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, 360 Huntington Ave, Boston, MA, 02115, USA
| | - Mark van den Boogaard
- Department of Intensive Care, Radboud Institute for Health Sciences, Radboud University Medical Center, P.O. Box 9101, 6500, HB, Nijmegen, the Netherlands
| | - Johannes G van der Hoeven
- Department of Intensive Care, Radboud Institute for Health Sciences, Radboud University Medical Center, P.O. Box 9101, 6500, HB, Nijmegen, the Netherlands
| | - Peter Pickkers
- Department of Intensive Care, Radboud Institute for Health Sciences, Radboud University Medical Center, P.O. Box 9101, 6500, HB, Nijmegen, the Netherlands
| | - Becky A Briesacher
- Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, 360 Huntington Ave, Boston, MA, 02115, USA
| | - Jane S Saczynski
- Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, 360 Huntington Ave, Boston, MA, 02115, USA
| | - John L Griffith
- Department of Health Sciences, Bouve College of Health Sciences, Northeastern University, 360 Huntington Ave, Boston, MA, 02115, USA
| | - John W Devlin
- Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, 360 Huntington Ave, Boston, MA, 02115, USA.
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Sanghai S, Wong C, Wang Z, Clive P, Tran W, Waring M, Goldberg R, Hayward R, Saczynski JS, McManus DD. Rates of Potentially Inappropriate Dosing of Direct-Acting Oral Anticoagulants and Associations With Geriatric Conditions Among Older Patients With Atrial Fibrillation: The SAGE-AF Study. J Am Heart Assoc 2020; 9:e014108. [PMID: 32146898 PMCID: PMC7335533 DOI: 10.1161/jaha.119.014108] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [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: 12/25/2022]
Abstract
Background Direct‐acting oral anticoagulant (DOAC) dosing guidelines for atrial fibrillation recommend dose alteration based on age, renal function, body weight, and drug‐drug interactions. There is paucity of data describing the frequency and factors associated with prescription of potentially inappropriate doses. Methods and Results In the ongoing SAGE‐AF (Systematic Assessment of Geriatric Elements in Atrial Fibrillation) study, we performed geriatric assessments (frailty, cognitive impairment, sensory impairments, social isolation, and depression) for participants with atrial fibrillation (age ≥65 years, CHA2DS2VASc ≥2, no anticoagulant contraindications). We developed an algorithm to analyze DOAC dose appropriateness accounting for drug‐drug interactions, age, renal function, and body weight. We also examined whether geriatric impairments were related to inappropriate dosing. Of 1064 patients prescribed anticoagulants, 460 received a DOAC. Participants were aged 74±7 years, 49% were women, and 82% were white. A quarter (23%; n=105) of participants received inappropriate DOAC dose, of whom 82 (78%) were underdosed and 23 (22%) were overdosed. Among participants receiving an inappropriate dose, 12 (11%) were identified using the drug‐drug interactions criteria and would have otherwise been misclassified. In multivariable regression analyses, older age, higher CHA2DS2VASc score, and history of renal failure were associated with inappropriate DOAC dosing (P<0.05). Geriatric conditions were not associated with inappropriate dosing. Conclusions In this cohort, over 20% of older patients with atrial fibrillation treated with DOACs were prescribed an inappropriate dose, with most being underdosed. Drug‐drug interactions were common. Factors that influence prescription of guideline‐nonadherent doses may be perception of higher bleeding risk or presence of renal failure in addition to lack of familiarity with dosing guidelines.
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Affiliation(s)
- Saket Sanghai
- Knight Cardiovascular InstituteOregon Health & Science UniversityPortlandOR
| | - Cecillia Wong
- Cardiology DivisionDepartment of MedicineUniversity of Massachusetts Medical SchoolWorcesterMA
| | - Ziyue Wang
- Department of Population and Quantitative Health SciencesUniversity of Massachusetts Medical SchoolWorcesterMA
| | - Pia Clive
- Department of PharmacyUniversity of Massachusetts Memorial Medical CenterWorcesterMA
| | - Wenisa Tran
- Department of PharmacyUniversity of Massachusetts Memorial Medical CenterWorcesterMA
| | - Molly Waring
- Department of Allied Health SciencesUniversity of ConnecticutStorrsCT
| | - Robert Goldberg
- Department of Population and Quantitative Health SciencesUniversity of Massachusetts Medical SchoolWorcesterMA
| | - Robert Hayward
- Kaiser Permanente Santa Clara Medical CenterSanta ClaraCA
| | - Jane S. Saczynski
- Department of Pharmacy and Health System SciencesNortheastern UniversityBostonMA
| | - David D. McManus
- Cardiology DivisionDepartment of MedicineUniversity of Massachusetts Medical SchoolWorcesterMA
- Department of Population and Quantitative Health SciencesUniversity of Massachusetts Medical SchoolWorcesterMA
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35
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Kapoor A, Amroze A, Vakil F, Crawford S, Der J, Mathew J, Alper E, Yogaratnam D, Javed S, Elhag R, Lin A, Narayanan S, Bartlett D, Nagy A, Shagoury BK, Fischer MA, Mazor KM, Saczynski JS, Ashburner JM, Lopes R, McManus DD. SUPPORT-AF II: Supporting Use of Anticoagulants Through Provider Profiling of Oral Anticoagulant Therapy for Atrial Fibrillation. Circ Cardiovasc Qual Outcomes 2020; 13:e005871. [DOI: 10.1161/circoutcomes.119.005871] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Previous provider-directed electronic messaging interventions have not by themselves improved anticoagulation use in patients with atrial fibrillation. Direct engagement with providers using academic detailing coupled with electronic messaging may overcome the limitations of the prior interventions.
Methods and Results:
We randomized outpatient providers affiliated with our health system in a 2.5:1 ratio to our electronic profiling/messaging combined with academic detailing intervention. In the intervention, we emailed providers monthly reports of their anticoagulation percentage relative to peers for atrial fibrillation patients with elevated stroke risk (CHA
2
DS
2
-VASc ≥2). We also sent electronic medical record-based messages shortly before an appointment with an anticoagulation-eligible but untreated atrial fibrillation patient. Providers had the option to send responses with explanations for prescribing decisions. We also offered to meet with intervention providers using an academic detailing approach developed based on knowledge gaps discussed in provider focus groups. To assess feasibility, we tracked provider review of our messages. To assess effectiveness, we measured the change in anticoagulation for patients of intervention providers relative to controls. We identified 85 intervention and 34 control providers taking care of 3591 and 1908 patients, respectively; 33 intervention providers participated in academic detailing. More than 80% of intervention providers read our emails, and 98% of the time a provider reviewed our in-basket messages. Replies to messages identified patient refusal as the most common reason for patients not being on anticoagulation (11.2%). For the group of patients not on anticoagulation at baseline assigned to an intervention versus control provider, the adjusted percent increase in the use of anticoagulation over 6 months was 5.2% versus 7.4%, respectively (
P
=0.21).
Conclusions:
Our electronic messaging and academic detailing intervention was feasible but did not increase anticoagulation use. Patient-directed interventions or provider interventions targeting patients declining anticoagulation may be necessary to raise the rate of anticoagulation.
Clinical Trial Registration
URL:
http://www.clinicaltrials.gov
. Unique identifier: NCT03583008.
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Affiliation(s)
- Alok Kapoor
- University of Massachusetts Memorial Health Care, Worcester (A.K., A.A, E.A., R.E., D.D.M.)
- University of Massachusetts Medical School, Worcester (A.K., S.C., J.M., E.A., S.J., R.E., A.L., S.N., A.N., K.M.M., J.S.S., D.D.M.)
- Meyers Primary Care Institute, a joint endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester (A.K., A.A., K.M.M., D.D.M.)
| | - Azraa Amroze
- University of Massachusetts Memorial Health Care, Worcester (A.K., A.A, E.A., R.E., D.D.M.)
- Meyers Primary Care Institute, a joint endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester (A.K., A.A., K.M.M., D.D.M.)
| | - Fatima Vakil
- Abigail Wexner Research Institute, Nationwide Children’s Hospital, Columbus, OH (F.V.)
| | - Sybil Crawford
- University of Massachusetts Medical School, Worcester (A.K., S.C., J.M., E.A., S.J., R.E., A.L., S.N., A.N., K.M.M., J.S.S., D.D.M.)
| | | | - Jomol Mathew
- University of Massachusetts Medical School, Worcester (A.K., S.C., J.M., E.A., S.J., R.E., A.L., S.N., A.N., K.M.M., J.S.S., D.D.M.)
| | - Eric Alper
- University of Massachusetts Memorial Health Care, Worcester (A.K., A.A, E.A., R.E., D.D.M.)
- University of Massachusetts Medical School, Worcester (A.K., S.C., J.M., E.A., S.J., R.E., A.L., S.N., A.N., K.M.M., J.S.S., D.D.M.)
| | - Dinesh Yogaratnam
- Mass College of Pharmacy and Health Sciences, Worcester, MA (D.Y., D.B.)
| | - Saud Javed
- University of Massachusetts Medical School, Worcester (A.K., S.C., J.M., E.A., S.J., R.E., A.L., S.N., A.N., K.M.M., J.S.S., D.D.M.)
| | - Rasha Elhag
- University of Massachusetts Memorial Health Care, Worcester (A.K., A.A, E.A., R.E., D.D.M.)
- University of Massachusetts Medical School, Worcester (A.K., S.C., J.M., E.A., S.J., R.E., A.L., S.N., A.N., K.M.M., J.S.S., D.D.M.)
| | - Abraham Lin
- University of Massachusetts Medical School, Worcester (A.K., S.C., J.M., E.A., S.J., R.E., A.L., S.N., A.N., K.M.M., J.S.S., D.D.M.)
| | - Siddhartha Narayanan
- University of Massachusetts Medical School, Worcester (A.K., S.C., J.M., E.A., S.J., R.E., A.L., S.N., A.N., K.M.M., J.S.S., D.D.M.)
| | - Donna Bartlett
- Mass College of Pharmacy and Health Sciences, Worcester, MA (D.Y., D.B.)
| | - Ahmed Nagy
- University of Massachusetts Medical School, Worcester (A.K., S.C., J.M., E.A., S.J., R.E., A.L., S.N., A.N., K.M.M., J.S.S., D.D.M.)
| | - Bevin Kathleen Shagoury
- The National Resource Center for Academic Detailing, Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital, Boston, MA (B.K.S., M.A.F.)
| | - Michael A. Fischer
- The National Resource Center for Academic Detailing, Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital, Boston, MA (B.K.S., M.A.F.)
| | - Kathleen M. Mazor
- University of Massachusetts Medical School, Worcester (A.K., S.C., J.M., E.A., S.J., R.E., A.L., S.N., A.N., K.M.M., J.S.S., D.D.M.)
- Meyers Primary Care Institute, a joint endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester (A.K., A.A., K.M.M., D.D.M.)
| | - Jane S. Saczynski
- University of Massachusetts Medical School, Worcester (A.K., S.C., J.M., E.A., S.J., R.E., A.L., S.N., A.N., K.M.M., J.S.S., D.D.M.)
- Northeastern University, Boston, MA (J.D., J.S.S.)
| | - Jeffrey M. Ashburner
- Division of General Internal Medicine, Massachusetts General Hospital, Boston (J.M.A.)
| | - Renato Lopes
- Duke Clinical Research Institute, Durham, NC (R.L.)
| | - David D. McManus
- University of Massachusetts Memorial Health Care, Worcester (A.K., A.A, E.A., R.E., D.D.M.)
- University of Massachusetts Medical School, Worcester (A.K., S.C., J.M., E.A., S.J., R.E., A.L., S.N., A.N., K.M.M., J.S.S., D.D.M.)
- Meyers Primary Care Institute, a joint endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon Health, Worcester (A.K., A.A., K.M.M., D.D.M.)
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36
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Marino FR, Lessard DM, Saczynski JS, McManus DD, Silverman-Lloyd LG, Benson CM, Blaha MJ, Waring ME. Gait Speed and Mood, Cognition, and Quality of Life in Older Adults With Atrial Fibrillation. J Am Heart Assoc 2019; 8:e013212. [PMID: 31735113 PMCID: PMC6915300 DOI: 10.1161/jaha.119.013212] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [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: 01/20/2023]
Abstract
Background Low gait speed has been linked with impaired mood, cognition, and quality of life (QOL) in older adults. We examined whether low gait speed was associated with impaired mood, cognition, and QOL among older adults with atrial fibrillation (AF). Methods and Results Participants (n=1185) had a diagnosis of AF, aged ≥65 years, CHA2DS2VASc ≥2 and had no contraindications to anticoagulation. Participants completed a 15‐foot walk test, and low gait speed was categorized using cutoffs from the Fried Frailty Index. Participants self‐reported measures of depressive symptoms (Patient Health Questionnaire 9 ≥10), anxiety symptoms (Generalized Anxiety Disorder 7 ≥10), cognitive impairment (Montreal Cognitive Assessment ≤23), and potentially impaired Atrial Fibrillation Effect Quality‐of‐Life Questionnaire <80. Participants were on average aged 75.3 (SD: 7.0) years, 48.0% were women, and 85.5% were non‐Hispanic white; 85.6% were taking an oral anticoagulant, 26.1% had low gait speed, 8.4% had elevated depressive symptoms, 5.7% had elevated anxiety symptoms, 41.1% were cognitively impaired, and 41.6% had potentially impaired AF‐related QOL. Participants with low gait speed were significantly more likely to have elevated depressive symptoms (adjusted odds ratio: 2.1, 95% CI: 1.3–3.4), elevated anxiety symptoms (adjusted odds ratio: 2.2, 95% CI: 1.2–3.9), and cognitive impairment (adjusted odds ratio: 1.5, 95% CI: 1.1–2.1). Impaired AF‐related QOL did not differ by gait speed after adjustment for clinical characteristics (adjusted odds ratio: 1.1, 95% CI: 0.8–1.5). Conclusions Twenty‐six percent of older adults with AF had low gait speed, and low gait speed was associated with impaired mood and cognition. Further research is needed to determine whether declines in gait speed lead to impaired mood and cognition or whether these conditions develop concurrently.
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Affiliation(s)
- Francesca R Marino
- Division of Cardiology Department of Medicine University of Massachusetts Medical School Worcester MA
| | - Darleen M Lessard
- Department of Population and Quantitative Health Sciences University of Massachusetts Medical School Worcester MA
| | - Jane S Saczynski
- Department of Pharmacy and Health System Sciences Northeastern University Boston MA
| | - David D McManus
- Division of Cardiology Department of Medicine University of Massachusetts Medical School Worcester MA.,Department of Population and Quantitative Health Sciences University of Massachusetts Medical School Worcester MA
| | - Luke G Silverman-Lloyd
- University of California, Berkeley - University of California, San Francisco Joint Medical Program UC Berkeley School of Public Health Berkeley CA.,Ciccarone Center for the Prevention of Cardiovascular Disease Johns Hopkins School of Medicine Baltimore MD
| | | | - Michael J Blaha
- Ciccarone Center for the Prevention of Cardiovascular Disease Johns Hopkins School of Medicine Baltimore MD
| | - Molly E Waring
- Department of Allied Health Sciences University of Connecticut Storrs CT
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37
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Waring ME, Hills MT, Lessard DM, Saczynski JS, Libby BA, Holovatska MM, Kapoor A, Kiefe CI, McManus DD. Characteristics Associated With Facebook Use and Interest in Digital Disease Support Among Older Adults With Atrial Fibrillation: Cross-Sectional Analysis of Baseline Data From the Systematic Assessment of Geriatric Elements in Atrial Fibrillation (SAGE-AF) Cohort. JMIR Cardio 2019; 3:e15320. [PMID: 31758791 PMCID: PMC6883367 DOI: 10.2196/15320] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 08/28/2019] [Accepted: 08/31/2019] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Online support groups for atrial fibrillation (AF) and apps to detect and manage AF exist, but the scientific literature does not describe which patients are interested in digital disease support. OBJECTIVE The objective of this study was to describe characteristics associated with Facebook use and interest in digital disease support among older patients with AF who used the internet. METHODS We used baseline data from the Systematic Assessment of Geriatric Elements in Atrial Fibrillation (SAGE-AF), a prospective cohort of older adults (≥65 years) with AF at high stroke risk. Participants self-reported demographics, clinical characteristics, and Facebook and technology use. Online patients (internet use in the past 4 weeks) were asked whether they would be interested in participating in an online support AF community. Mobile users (owns smartphone and/or tablet) were asked about interest in communicating with their health care team about their AF-related health using a secure app. Logistic regression models identified crude and multivariable predictors of Facebook use and interest in digital disease support. RESULTS Online patients (N=816) were aged 74.2 (SD 6.6) years, 47.8% (390/816) were female, and 91.1% (743/816) were non-Hispanic white. Roughly half (52.5%; 428/816) used Facebook. Facebook use was more common among women (adjusted odds ratio [aOR] 2.21, 95% CI 1.66-2.95) and patients with mild to severe depressive symptoms (aOR 1.50, 95% CI 1.08-2.10) and less common among patients aged ≥85 years (aOR 0.27, 95% CI 0.15-0.48). Forty percent (40.4%; 330/816) reported interest in an online AF patient community. Interest in an online AF patient community was more common among online patients with some college/trade school or Bachelors/graduate school (aOR 1.70, 95% CI 1.10-2.61 and aOR 1.82, 95% CI 1.13-2.92, respectively), obesity (aOR 1.65, 95% CI 1.08-2.52), online health information seeking at most weekly or multiple times per week (aOR 1.84, 95% CI 1.32-2.56 and aOR 2.78, 95% CI 1.86-4.16, respectively), and daily Facebook use (aOR 1.76, 95% CI 1.26-2.46). Among mobile users, 51.8% (324/626) reported interest in communicating with their health care team via a mobile app. Interest in app-mediated communication was less likely among women (aOR 0.48, 95% CI 0.34-0.68) and more common among online patients who had completed trade school/some college versus high school/General Educational Development (aOR 1.95, 95% CI 1.17-3.22), sought online health information at most weekly or multiple times per week (aOR 1.86, 95% CI 1.27-2.74 and aOR 2.24, 95% CI 1.39-3.62, respectively), and had health-related apps (aOR 3.92, 95% CI 2.62-5.86). CONCLUSIONS Among older adults with AF who use the internet, technology use and demographics are associated with interest in digital disease support. Clinics and health care providers may wish to encourage patients to join an existing online support community for AF and explore opportunities for app-mediated patient-provider communication.
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Affiliation(s)
- Molly E Waring
- Department of Allied Health Sciences, University of Connecticut, Storrs, CT, United States
| | - Mellanie T Hills
- StopAfib.org, American Foundation for Women's Health, Decatur, TX, United States
| | - Darleen M Lessard
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, United States
| | - Jane S Saczynski
- Department of Pharmacy and Health System Sciences, Northeastern University, Boston, MA, United States
| | - Brooke A Libby
- Department of Allied Health Sciences, University of Connecticut, Storrs, CT, United States
| | - Marta M Holovatska
- Department of Allied Health Sciences, University of Connecticut, Storrs, CT, United States
| | - Alok Kapoor
- Division of Hospital Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester, MA, United States
| | - Catarina I Kiefe
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, United States
| | - David D McManus
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, United States.,Division of Cardiology, Department of Medicine, University of Massachusetts Medical School, Worcester, MA, United States
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38
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Forrester SN, McManus DD, Saczynski JS, Kiefe CI. RACE, BIOLOGICAL AGE, AND COGNITION: THE SYSTEMATIC ASSESSMENT OF GERIATRIC ELEMENTS IN ATRIAL FIBRILLATION STUDY. Innov Aging 2019. [PMCID: PMC6840809 DOI: 10.1093/geroni/igz038.1175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Atrial Fibrillation (AF) is associated with dementia and cognitive decline. AF is less prevalent among Blacks than Whites, although AF-related complications are more common in Blacks. In the general population, all-cause cognitive decline and dementia are more prevalent among Blacks than Whites. Thus, studying diverse populations with AF may advance our understanding of racial disparities in cognitive functioning. We created a measure of multisystem dysregulation (weathering), which includes but is more encompassing than aging, and examined its association with racial differences in cognition using data from the SAGE-AF study, a prospective cohort of >65-year olds with AF, at high stroke risk, and eligible for anticoagulation. Biological (as opposed to chronological) age among 974 participants was calculated using the Klemera and Doubal method using biomarkers representing physiological functioning, metabolism, and blood pressure. We defined weathering as the difference between biological and chronological age (weathering >0 indicates that biological age is higher than chronological age). We measured the association between weathering and the Montreal Cognitive Assessment (MoCA) score. Mean weathering (SD) was -0.7 (11.5) and 4.3 (12.6) for whites and non-whites, respectively. There was an interaction between race/ethnicity and weathering on cognition (P=0.004). In stratified analyses, higher weathering was associated with a lower MoCA score among both Whites and non-Whites but more so among non-whites (B = -0.09, 95% CI: -0.17, -0.02) for Whites (B = -0.03, 95% CI: -0.06, -0.01) for non-whites. Aging-related multisystem dysregulation is more strongly associated with worse cognition in non-whites than in whites.
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Affiliation(s)
- Sarah N Forrester
- University of Massachusetts Medical School, Worcester, Massachusetts, United States
| | - David D McManus
- University of Massachusetts Medical School, Worcester, Massachusetts, United States
| | | | - Catarina I Kiefe
- University of Massachusetts Medical School, Worcester, Massachusetts, United States
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39
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Saczynski JS, Sanghai SR, Kiefe CI, Lessard D, Marino F, Waring ME, Parish D, Helm R, Sogade F, Goldberg R, Gurwitz J, Wang W, Mailhot T, Bamgbade B, Barton B, McManus DD. Geriatric Elements and Oral Anticoagulant Prescribing in Older Atrial Fibrillation Patients: SAGE-AF. J Am Geriatr Soc 2019; 68:147-154. [PMID: 31574165 DOI: 10.1111/jgs.16178] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [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: 06/25/2019] [Revised: 08/23/2019] [Accepted: 08/23/2019] [Indexed: 01/19/2023]
Abstract
OBJECTIVES Oral anticoagulants are the cornerstone of stroke prevention in high-risk patients with atrial fibrillation (AF). Geriatric elements, such as cognitive impairment and frailty, commonly occur in these patients and are often cited as reasons for not prescribing oral anticoagulants. We sought to systematically assess geriatric impairments in patients with AF and determine whether they were associated with oral anticoagulant prescribing. DESIGN Cross-sectional analysis of baseline data from the ongoing Systematic Assessment of Geriatric Elements in Atrial Fibrillation (SAGE-AF) prospective cohort study. SETTING Multicenter study with site locations in Massachusetts and Georgia that recruited participants from cardiology, electrophysiology, and primary care clinics from 2016 to 2018. PARTICIPANTS Participants with AF age 65 years or older, CHA2 DS2 -VASc (congestive heart failure; hypertension; aged ≥75 y [doubled]; diabetes mellitus; prior stroke, transient ischemic attack, or thromboembolism [doubled]; vascular disease; age 65-74; female sex) score of 2 or higher, and no oral anticoagulant contraindications (n = 1244). MEASUREMENTS A six-component geriatric assessment included validated measures of frailty, cognitive function, social support, depressive symptoms, vision, and hearing. Oral anticoagulant use was abstracted from the medical record. RESULTS A total of 1244 participants (mean age = 76 y; 49% female; 85% white) were enrolled; 42% were cognitively impaired, 14% frail, 53% pre-frail, 12% socially isolated, and 29% had depressive symptoms. Oral anticoagulants were prescribed to 86% of the cohort. Oral anticoagulant prescribing did not vary according to any of the geriatric elements (adjusted odds ratios [ORs] for oral anticoagulant prescribing and cognitive impairment: OR = .75; 95% confidence interval [CI] = .51-1.09; frail OR = .69; 95% CI = .35-1.36; social isolation OR = .90; 95% CI = .52-1.54; depression OR = .79; 95% CI = .49-1.27; visual impairment OR = .98; 95% CI = .65-1.48; and hearing impairment OR = 1.05; 95% CI = .71-1.54). CONCLUSION Geriatric impairments, particularly cognitive impairment and frailty, were common in our cohort, but treatment with oral anticoagulants did not differ by impairment status. These geriatric impairments are commonly cited as reasons for not prescribing oral anticoagulants, suggesting that prescribers may either be unaware or deliberately ignoring the presence of these factors in clinical settings. J Am Geriatr Soc 68:147-154, 2019.
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Affiliation(s)
- Jane S Saczynski
- Department of Pharmacy and Health System Sciences, Northeastern University, Boston, Massachusetts
| | - Saket R Sanghai
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Catarina I Kiefe
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Darleen Lessard
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts.,Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Francesca Marino
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Molly E Waring
- Department of Allied Health Sciences, University of Connecticut, Storrs, Connecticut
| | - David Parish
- Department of Community Medicine/ Internal Medicine, Mercer University School of Medicine, Macon, Georgia
| | - Robert Helm
- Department of Medicine, Boston University Medical Center, Boston, Massachusetts
| | - Felix Sogade
- Department of Medicine, Mercer University School of Medicine, Mercer, Georgia
| | - Robert Goldberg
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Jerry Gurwitz
- Geriatric Medicine Division, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Weijia Wang
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Tanya Mailhot
- Department of Pharmacy and Health System Sciences, Northeastern University, Boston, Massachusetts.,Montreal Heart Institute Research Center, Montreal, Quebec, Canada
| | - Benita Bamgbade
- Department of Pharmacy and Health System Sciences, Northeastern University, Boston, Massachusetts
| | - Bruce Barton
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - David D McManus
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts.,Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
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40
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Kapoor A, Amroze A, Golden J, Crawford S, O'Day K, Elhag R, Nagy A, Lubitz SA, Saczynski JS, Mathew J, McManus DD. SUPPORT-AF: Piloting a Multi-Faceted, Electronic Medical Record-Based Intervention to Improve Prescription of Anticoagulation. J Am Heart Assoc 2018; 7:e009946. [PMID: 30371161 PMCID: PMC6201433 DOI: 10.1161/jaha.118.009946] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [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: 06/04/2018] [Accepted: 07/24/2018] [Indexed: 01/24/2023]
Abstract
Background Only 50% of eligible atrial fibrillation ( AF ) patients receive anticoagulation ( AC ). Feasibility and effectiveness of electronic medical record (EMR)-based interventions to profile and raise provider AC percentage is poorly understood. The SUPPORT-AF (Supporting Use of AC Through Provider Profiling of Oral AC Therapy for AF) study aims to improve rates of adherence to AC guidelines by developing and delivering supportive tools based on the EMR to providers treating patients with AF. Methods and Results We emailed cardiologists and community-based primary care providers affiliated with our institution reports of their AC percentage relative to peers. We also sent an electronic medical record-based message to these providers the day before an appointment with an atrial fibrillation patient who was eligible but not receiving AC . The electronic medical record message asked the provider to discuss AC with the patient if he or she deemed it appropriate. To assess feasibility, we tracked provider review of our correspondence. We also tracked the change in AC for intervention providers relative to alternate primary care providers not receiving our intervention. We identified 3786, 1054, and 566 patients cared for by 49 cardiology providers, 90 community-based primary care providers, and 88 control providers, respectively. At baseline, the percentage of AC was 71.3%, 63.5%, and 58.3% for these 3 respective groups. Intervention providers reviewed our e-mails and electronic medical record messages 45% and 96% of the time, respectively. For providers responding, patient refusal was the most common reason for patients not being on AC (21%) followed by high bleeding risk (19%). At follow-up 10 weeks later, change in AC was no different for either cardiology or community-based primary care providers relative to controls (0.2% lower and 0.01% higher, respectively). Conclusions Our intervention profiling AC was feasible, but not sufficient to increase AC in our population.
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Affiliation(s)
- Alok Kapoor
- University of Massachusetts Memorial Health CareWorcesterMA
- University of Massachusetts Medical SchoolWorcesterMA
- Meyers Primary Care Institutea joint endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon HealthWorcesterMA
| | - Azraa Amroze
- Meyers Primary Care Institutea joint endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon HealthWorcesterMA
| | | | | | - Kevin O'Day
- University of Massachusetts Memorial Health CareWorcesterMA
| | - Rasha Elhag
- University of Massachusetts Memorial Health CareWorcesterMA
| | - Ahmed Nagy
- University of Massachusetts Memorial Health CareWorcesterMA
| | - Steve A. Lubitz
- Massachusetts General HospitalBostonMA
- Harvard Medical SchoolBostonMA
| | - Jane S. Saczynski
- University of Massachusetts Medical SchoolWorcesterMA
- Meyers Primary Care Institutea joint endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon HealthWorcesterMA
- Northeastern UniversityBostonMA
| | - Jomol Mathew
- University of Massachusetts Medical SchoolWorcesterMA
| | - David D. McManus
- University of Massachusetts Memorial Health CareWorcesterMA
- University of Massachusetts Medical SchoolWorcesterMA
- Meyers Primary Care Institutea joint endeavor of University of Massachusetts Medical School, Reliant Medical Group, and Fallon HealthWorcesterMA
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41
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Saczynski JS, McManus DD, Waring ME, Lessard D, Anatchkova MD, Gurwitz JH, Allison J, Ash AS, McManus RH, Parish DC, Goldberg RJ, Kiefe CI. Change in Cognitive Function in the Month After Hospitalization for Acute Coronary Syndromes: Findings From TRACE-CORE (Transition, Risks, and Actions in Coronary Events-Center for Outcomes Research and Education). Circ Cardiovasc Qual Outcomes 2018; 10:CIRCOUTCOMES.115.001669. [PMID: 29237744 DOI: 10.1161/circoutcomes.115.001669] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Accepted: 10/31/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Cognitive function is often impaired during hospitalization, but whether this impairment resolves or persists after discharge is unknown. METHODS AND RESULTS We enrolled (April 2011-May 2013) and interviewed during hospitalization and 1-month post-discharge 1521 nondemented acute coronary syndrome survivors enrolled in TRACE (Transitions, Risks and Actions in Coronary Events). Cognitive function was assessed using the Telephone Interview of Cognitive Status (range: 0-41) at both time points. Patients reported demographic and psychosocial characteristics and medical records were abstracted. Using the Telephone Interview of Cognitive Status cut point of ≤28, we defined 4 groups of cognitive change based on cognitive status during hospitalization and 1 month later: consistently impaired, transiently impaired, newly impaired, and consistently nonimpaired. Characteristics associated with cognitive change categories were examined using multinomial logistic regression. Participants were 67% male, 84% non-Hispanic white, with mean age±SD 62±11 years; 16% (n=237) were cognitively impaired during hospitalization, and 11% (n=174) were impaired 1 month after discharge. Overall, 80% were consistently nonimpaired, 9% transiently impaired, 7% consistently impaired, and 4% newly impaired. Lower education level, minority status, low health literacy and numeracy, and higher severity of disease were independently associated with cognitive impairment during and after hospitalization. Male sex was associated with increased risk of cognitive impairment after hospital discharge. CONCLUSIONS Cognitive function changes during the transition from hospital to home after acute coronary syndrome are less favorable for men and those with psychosocial vulnerability. Assessing cognitive status both in hospital and post-discharge is important for detecting patients who could benefit from tailored transitional care including early follow-up and booster discharge instructions.
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Affiliation(s)
- Jane S Saczynski
- From the Department of Pharmacy and Health System Sciences, Northeastern University, Boston, MA (J.S.S.); Department of Medicine (D.D.M., J.H.G.) and Department of Quantitative Health Sciences (D.D.M., M.E.W., D.L., M.D.A., J.A., A.S.A., R.H.M., R.J.G., C.I.K.), University of Massachusetts Medical School, Worcester; Evidera, Lexington, MA (M.D.A.); Meyers Primary Care Institute, Worcester, MA (J.H.G.); and Department of Medicine, Mercer School of Medicine, Macon, GA (D.C.P.).
| | - David D McManus
- From the Department of Pharmacy and Health System Sciences, Northeastern University, Boston, MA (J.S.S.); Department of Medicine (D.D.M., J.H.G.) and Department of Quantitative Health Sciences (D.D.M., M.E.W., D.L., M.D.A., J.A., A.S.A., R.H.M., R.J.G., C.I.K.), University of Massachusetts Medical School, Worcester; Evidera, Lexington, MA (M.D.A.); Meyers Primary Care Institute, Worcester, MA (J.H.G.); and Department of Medicine, Mercer School of Medicine, Macon, GA (D.C.P.)
| | - Molly E Waring
- From the Department of Pharmacy and Health System Sciences, Northeastern University, Boston, MA (J.S.S.); Department of Medicine (D.D.M., J.H.G.) and Department of Quantitative Health Sciences (D.D.M., M.E.W., D.L., M.D.A., J.A., A.S.A., R.H.M., R.J.G., C.I.K.), University of Massachusetts Medical School, Worcester; Evidera, Lexington, MA (M.D.A.); Meyers Primary Care Institute, Worcester, MA (J.H.G.); and Department of Medicine, Mercer School of Medicine, Macon, GA (D.C.P.)
| | - Darleen Lessard
- From the Department of Pharmacy and Health System Sciences, Northeastern University, Boston, MA (J.S.S.); Department of Medicine (D.D.M., J.H.G.) and Department of Quantitative Health Sciences (D.D.M., M.E.W., D.L., M.D.A., J.A., A.S.A., R.H.M., R.J.G., C.I.K.), University of Massachusetts Medical School, Worcester; Evidera, Lexington, MA (M.D.A.); Meyers Primary Care Institute, Worcester, MA (J.H.G.); and Department of Medicine, Mercer School of Medicine, Macon, GA (D.C.P.)
| | - Milena D Anatchkova
- From the Department of Pharmacy and Health System Sciences, Northeastern University, Boston, MA (J.S.S.); Department of Medicine (D.D.M., J.H.G.) and Department of Quantitative Health Sciences (D.D.M., M.E.W., D.L., M.D.A., J.A., A.S.A., R.H.M., R.J.G., C.I.K.), University of Massachusetts Medical School, Worcester; Evidera, Lexington, MA (M.D.A.); Meyers Primary Care Institute, Worcester, MA (J.H.G.); and Department of Medicine, Mercer School of Medicine, Macon, GA (D.C.P.)
| | - Jerry H Gurwitz
- From the Department of Pharmacy and Health System Sciences, Northeastern University, Boston, MA (J.S.S.); Department of Medicine (D.D.M., J.H.G.) and Department of Quantitative Health Sciences (D.D.M., M.E.W., D.L., M.D.A., J.A., A.S.A., R.H.M., R.J.G., C.I.K.), University of Massachusetts Medical School, Worcester; Evidera, Lexington, MA (M.D.A.); Meyers Primary Care Institute, Worcester, MA (J.H.G.); and Department of Medicine, Mercer School of Medicine, Macon, GA (D.C.P.)
| | - Jeroan Allison
- From the Department of Pharmacy and Health System Sciences, Northeastern University, Boston, MA (J.S.S.); Department of Medicine (D.D.M., J.H.G.) and Department of Quantitative Health Sciences (D.D.M., M.E.W., D.L., M.D.A., J.A., A.S.A., R.H.M., R.J.G., C.I.K.), University of Massachusetts Medical School, Worcester; Evidera, Lexington, MA (M.D.A.); Meyers Primary Care Institute, Worcester, MA (J.H.G.); and Department of Medicine, Mercer School of Medicine, Macon, GA (D.C.P.)
| | - Arlene S Ash
- From the Department of Pharmacy and Health System Sciences, Northeastern University, Boston, MA (J.S.S.); Department of Medicine (D.D.M., J.H.G.) and Department of Quantitative Health Sciences (D.D.M., M.E.W., D.L., M.D.A., J.A., A.S.A., R.H.M., R.J.G., C.I.K.), University of Massachusetts Medical School, Worcester; Evidera, Lexington, MA (M.D.A.); Meyers Primary Care Institute, Worcester, MA (J.H.G.); and Department of Medicine, Mercer School of Medicine, Macon, GA (D.C.P.)
| | - Richard H McManus
- From the Department of Pharmacy and Health System Sciences, Northeastern University, Boston, MA (J.S.S.); Department of Medicine (D.D.M., J.H.G.) and Department of Quantitative Health Sciences (D.D.M., M.E.W., D.L., M.D.A., J.A., A.S.A., R.H.M., R.J.G., C.I.K.), University of Massachusetts Medical School, Worcester; Evidera, Lexington, MA (M.D.A.); Meyers Primary Care Institute, Worcester, MA (J.H.G.); and Department of Medicine, Mercer School of Medicine, Macon, GA (D.C.P.)
| | - David C Parish
- From the Department of Pharmacy and Health System Sciences, Northeastern University, Boston, MA (J.S.S.); Department of Medicine (D.D.M., J.H.G.) and Department of Quantitative Health Sciences (D.D.M., M.E.W., D.L., M.D.A., J.A., A.S.A., R.H.M., R.J.G., C.I.K.), University of Massachusetts Medical School, Worcester; Evidera, Lexington, MA (M.D.A.); Meyers Primary Care Institute, Worcester, MA (J.H.G.); and Department of Medicine, Mercer School of Medicine, Macon, GA (D.C.P.)
| | - Robert J Goldberg
- From the Department of Pharmacy and Health System Sciences, Northeastern University, Boston, MA (J.S.S.); Department of Medicine (D.D.M., J.H.G.) and Department of Quantitative Health Sciences (D.D.M., M.E.W., D.L., M.D.A., J.A., A.S.A., R.H.M., R.J.G., C.I.K.), University of Massachusetts Medical School, Worcester; Evidera, Lexington, MA (M.D.A.); Meyers Primary Care Institute, Worcester, MA (J.H.G.); and Department of Medicine, Mercer School of Medicine, Macon, GA (D.C.P.)
| | - Catarina I Kiefe
- From the Department of Pharmacy and Health System Sciences, Northeastern University, Boston, MA (J.S.S.); Department of Medicine (D.D.M., J.H.G.) and Department of Quantitative Health Sciences (D.D.M., M.E.W., D.L., M.D.A., J.A., A.S.A., R.H.M., R.J.G., C.I.K.), University of Massachusetts Medical School, Worcester; Evidera, Lexington, MA (M.D.A.); Meyers Primary Care Institute, Worcester, MA (J.H.G.); and Department of Medicine, Mercer School of Medicine, Macon, GA (D.C.P.)
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Kundu A, Day KO, Lessard DM, Gore JM, Lubitz SA, Yu H, Akhter MW, Fisher DZ, Hayward RM, Henninger N, Saczynski JS, Walkey AJ, Kapoor A, Yarzebski J, Goldberg RJ, McManus DD. Recent Trends in Oral Anticoagulant Use and Post-Discharge Complications Among Atrial Fibrillation Patients with Acute Myocardial Infarction. J Atr Fibrillation 2018; 10:1749. [PMID: 29988239 PMCID: PMC6006973 DOI: 10.4022/jafib.1749] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [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: 02/22/2018] [Revised: 02/23/2018] [Accepted: 02/24/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) is a common complication of acute myocardial infarction (AMI).The CHA2DS2VAScand CHADS2risk scoresare used to identifypatients with AF at risk for strokeand to guide oral anticoagulants (OAC) use, including patients with AMI. However, the epidemiology of AF, further stratifiedaccording to patients' risk of stroke, has not been wellcharacterized among those hospitalized for AMI. METHODS We examined trends in the frequency of AF, rates of discharge OAC use, and post-discharge outcomes among 6,627 residents of the Worcester, Massachusetts area who survived hospitalization for AMI at 11 medical centers between 1997 and 2011. RESULTS A total of 1,050AMI patients had AF (16%) andthe majority (91%)had a CHA2DS2VAScscore >2.AF rates were highest among patients in the highest stroke risk group.In comparison to patients without AF, patients with AMI and AF in the highest stroke risk category had higher rates of post-discharge complications, including higher 30-day re-hospitalization [27 % vs. 17 %], 30-day post-discharge death [10 % vs. 5%], and 1-year post-discharge death [46 % vs. 18 %] (p < 0.001 for all). Notably, fewerthan half of guideline-eligible AF patientsreceived an OACprescription at discharge. Usage rates for other evidence-based therapiessuch as statins and beta-blockers,lagged in comparison to AMI patients free from AF. CONCLUSIONS Our findings highlight the need to enhance efforts towards stroke prevention among AMI survivors with AF.
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Affiliation(s)
- Amartya Kundu
- Department of Cardiology, University of Massachusetts Medical School, Worcester, MA, USA
| | - Kevin O Day
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Darleen M Lessard
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Joel M Gore
- Department of Cardiology, University of Massachusetts Medical School, Worcester, MA, USA
| | - Steven A Lubitz
- Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, MA, USA
| | - Hong Yu
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Mohammed W Akhter
- Department of Cardiology, University of Massachusetts Medical School, Worcester, MA, USA
| | - Daniel Z Fisher
- Department of Cardiology, University of Massachusetts Medical School, Worcester, MA, USA
| | - Robert M Hayward
- Department of Cardiology, University of Massachusetts Medical School, Worcester, MA, USA
| | - Nils Henninger
- Department of Neurology, University of Massachusetts Medical School, Worcester, MA, USA
| | - Jane S Saczynski
- Department of Pharmacy and Health System Sciences, Northeastern University, Boston, MA, USA
| | - Allan J Walkey
- Department of Medicine, Boston University School of Medicine, Boston, MA
| | - Alok Kapoor
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Jorge Yarzebski
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Robert J Goldberg
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - David D McManus
- Department of Cardiology, University of Massachusetts Medical School, Worcester, MA, USA
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Nishtala A, Piers RJ, Himali JJ, Beiser AS, Davis-Plourde KL, Saczynski JS, McManus DD, Benjamin EJ, Au R. Atrial fibrillation and cognitive decline in the Framingham Heart Study. Heart Rhythm 2017; 15:166-172. [PMID: 28943482 DOI: 10.1016/j.hrthm.2017.09.036] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND There is a paucity of longitudinal research investigating the relations between atrial fibrillation (AF) and domain-specific cognitive performance. OBJECTIVE The purpose of this study was to investigate the association between AF and cognitive performance cross-sectionally and longitudinally. METHODS Eligible participants were dementia- and stroke-free at the time of baseline neuropsychological (NP) assessment and underwent at least 1 additional NP assessment with at least 1-year inter-test interval. AF status was examined as a 2-level variable (prevalent AF, no AF) in cross-sectional analyses and then separately as a 3-level variable (prevalent AF, interim AF, no AF) in longitudinal analyses. We examined the association between AF status and cognitive performance with linear regression. We first adjusted models for age and sex and then for vascular risk factors and apolipoprotein ε4 (APOE4) status. RESULTS We studied 2682 participants of the Framingham Heart Study original and offspring cohorts. At the baseline NP assessment, 112 participants (4%) had AF (mean age 72 ± 9 years; 32% women). After adjustment for vascular risk factors and APOE4 status, prevalent AF was significantly associated with poorer attention; sex differences were also noted with men performing worse on tests of abstract reasoning and executive function, while women did better on a measure of executive function. Prevalent AF was significantly associated with longitudinal decline in executive function in the original cohort, and interim AF was significantly associated with longitudinal decline in executive function in the offspring cohort. CONCLUSION After accounting for vascular risk factor burden and APOE4 status, AF was associated with a vascular profile of change in cognitive function.
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Affiliation(s)
- Arvind Nishtala
- Department of Medicine, University of California, San Francisco, California
| | - Ryan J Piers
- Department of Psychological and Brain Sciences, Boston University, Boston, Massachusetts; Department of Neurology, Boston University School of Medicine, Boston, Massachusetts; The Framingham Heart Study, Framingham, Massachusetts
| | - Jayandra J Himali
- Department of Neurology, Boston University School of Medicine, Boston, Massachusetts; The Framingham Heart Study, Framingham, Massachusetts; Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts
| | - Alexa S Beiser
- Department of Neurology, Boston University School of Medicine, Boston, Massachusetts; The Framingham Heart Study, Framingham, Massachusetts; Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts
| | - Kendra L Davis-Plourde
- The Framingham Heart Study, Framingham, Massachusetts; Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts
| | - Jane S Saczynski
- Department of Medicine, University of Massachusetts, Worcester, Massachusetts
| | - David D McManus
- Department of Medicine, University of Massachusetts, Worcester, Massachusetts
| | - Emelia J Benjamin
- The Framingham Heart Study, Framingham, Massachusetts; Department of Medicine, Boston University School of Public Health, Boston, Massachusetts; Department of Anatomy & Neurobiology, Boston University School of Public Health, Boston, Massachusetts
| | - Rhoda Au
- Department of Neurology, Boston University School of Medicine, Boston, Massachusetts; The Framingham Heart Study, Framingham, Massachusetts; Department of Anatomy & Neurobiology, Boston University School of Public Health, Boston, Massachusetts; Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts.
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Aldrugh S, Sardana M, Henninger N, Saczynski JS, McManus DD. Atrial fibrillation, cognition and dementia: A review. J Cardiovasc Electrophysiol 2017; 28:958-965. [PMID: 28569383 DOI: 10.1111/jce.13261] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 05/19/2017] [Accepted: 05/22/2017] [Indexed: 12/15/2022]
Abstract
Atrial fibrillation (AF) is one of the most common types of cardiac arrhythmia, particularly among older adults. AF confers a 5-fold risk for thromboembolic stroke as well as a 2-fold higher risk for congestive heart failure, morbidity, and mortality. Although stroke remains an important and impactful complication of AF, recent studies have shown that AF is independently associated with other neurological disorders, including cognitive impairment and dementia, even after adjusting for prior ischemic stroke. We performed a review of the published literature on the association between AF and cognitive status. Further, we reviewed studies investigating the underlying mechanisms for this association and/or reporting the impact of AF treatment on cognitive function. While most published studies demonstrate associations between AF and impaired cognition, no AF treatment has yet been associated with a reduced incidence of cognitive decline or dementia.
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Affiliation(s)
- Summer Aldrugh
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Mayank Sardana
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Nils Henninger
- Department of Neurology, University of Massachusetts Medical School, Worcester, MA, USA.,Department of Psychiatry, University of Massachusetts Medical School, Worcester, MA, USA
| | - Jane S Saczynski
- Department of Pharmacy and Health System Sciences, Northeastern University, Boston, MA
| | - David D McManus
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
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Hajduk AM, Hyde JE, Waring ME, Lessard DM, McManus DD, Fauth EB, Lemon SC, Saczynski JS. Practical Care Support During the Early Recovery Period After Acute Coronary Syndrome. J Appl Gerontol 2017; 37:881-903. [PMID: 28380706 DOI: 10.1177/0733464816684621] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [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] Open
Abstract
OBJECTIVE To describe the prevalence and predictors of receipt of practical support among acute coronary syndrome (ACS) survivors during the early post-discharge period. METHOD 406 ACS patients were interviewed about receipt of practical (instrumental and informational) support during the week after discharge. Demographic, clinical, functional, and psychosocial predictors of instrumental and informational practical support were examined. RESULTS 81% of participants reported receiving practical support during the early post-discharge period: 75% reported receipt of instrumental support and 51% reported receipt of informational support. Men were less likely to report receiving certain types of practical support, whereas married participants and those with higher education, impaired health literacy, impaired activities of daily living, and in-hospital complications were more likely to report receiving certain types of practical support. CONCLUSION Receipt of practical support is very common among ACS survivors during the early post-discharge period, and type of support received differs according to patient characteristics.
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Darling CE, Dovancescu S, Saczynski JS, Riistama J, Sert Kuniyoshi F, Rock J, Meyer TE, McManus DD. Bioimpedance-Based Heart Failure Deterioration Prediction Using a Prototype Fluid Accumulation Vest-Mobile Phone Dyad: An Observational Study. JMIR Cardio 2017; 1:e1. [PMID: 31758769 PMCID: PMC6832026 DOI: 10.2196/cardio.6057] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [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: 06/06/2016] [Revised: 12/19/2016] [Accepted: 01/28/2017] [Indexed: 12/21/2022] Open
Abstract
Background Recurrent heart failure (HF) events are common in patients discharged after acute decompensated heart failure (ADHF). New patient-centered technologies are needed to aid in detecting HF decompensation. Transthoracic bioimpedance noninvasively measures pulmonary fluid retention. Objective The objectives of our study were to (1) determine whether transthoracic bioimpedance can be measured daily with a novel, noninvasive, wearable fluid accumulation vest (FAV) and transmitted using a mobile phone and (2) establish whether an automated algorithm analyzing daily thoracic bioimpedance values would predict recurrent HF events. Methods We prospectively enrolled patients admitted for ADHF. Participants were trained to use a FAV–mobile phone dyad and asked to transmit bioimpedance measurements for 45 consecutive days. We examined the performance of an algorithm analyzing changes in transthoracic bioimpedance as a predictor of HF events (HF readmission, diuretic uptitration) over a 75-day follow-up. Results We observed 64 HF events (18 HF readmissions and 46 diuretic uptitrations) in the 106 participants (67 years; 63.2%, 67/106, male; 48.1%, 51/106, with prior HF) who completed follow-up. History of HF was the only clinical or laboratory factor related to recurrent HF events (P=.04). Among study participants with sufficient FAV data (n=57), an algorithm analyzing thoracic bioimpedance showed 87% sensitivity (95% CI 82-92), 70% specificity (95% CI 68-72), and 72% accuracy (95% CI 70-74) for identifying recurrent HF events. Conclusions Patients discharged after ADHF can measure and transmit daily transthoracic bioimpedance using a FAV–mobile phone dyad. Algorithms analyzing thoracic bioimpedance may help identify patients at risk for recurrent HF events after hospital discharge.
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Affiliation(s)
- Chad Eric Darling
- UMass Memorial Health Care, Department of Emergency Medicine, University of Massachusetts Medical School, Worcester, MA, United States
| | | | - Jane S Saczynski
- Department of Pharmacy and Health Systems Sciences, Northeastern University, Boston, MA, United States
| | | | | | - Joseph Rock
- Philips Healthcare, Andover, MA, United States
| | - Theo E Meyer
- UMass Memorial Health Care, Department of Medicine, University of Massachusetts Medical School, Worcester, MA, United States
| | - David D McManus
- UMass Memorial Health Care, Department of Medicine, University of Massachusetts Medical School, Worcester, MA, United States
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Bull MJ, Boaz L, Maadooliat M, Hagle ME, Gettrust L, Greene MT, Holmes SB, Saczynski JS. Preparing Family Caregivers to Recognize Delirium Symptoms in Older Adults After Elective Hip or Knee Arthroplasty. J Am Geriatr Soc 2016; 65:e13-e17. [PMID: 27861701 DOI: 10.1111/jgs.14535] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [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: 12/01/2022]
Abstract
OBJECTIVES To test the feasibility of a telephone-based intervention that prepares family caregivers to recognize delirium symptoms and how to communicate their observations to healthcare providers. DESIGN Mixed-method, pre-post quasi-experimental design. SETTING A Midwest Veterans Affairs Medical Center and a nonprofit health system. PARTICIPANTS Forty-one family caregiver-older adult dyads provided consent; 34 completed the intervention. INTERVENTION Four telephone-based education modules using vignettes were completed during the 3 weeks before the older adult's hospital admission for elective hip or knee replacement. Each module required 20 to 30 minutes. MEASUREMENTS Interviews were conducted before the intervention and 2 weeks and 2 months after the older adult's hospitalization. A researcher completed the Confusion Assessment Method (CAM) and a family caregiver completed the Family Version of the Confusion Assessment Method (FAM-CAM) 2 days after surgery to assess the older adults for delirium symptoms. RESULTS Family caregivers' knowledge of delirium symptoms improved significantly from before the intervention to 2 weeks after the intervention and was maintained after the older adult's hospitalization. They also were able to recognize the presence and absence of delirium symptoms in the vignettes included in the intervention and in the older adult after surgery. In 94% of the cases, the family caregiver rating on the FAM-CAM approximately 2 days after the older adult's surgery agreed with the researcher rating on the CAM. Family caregivers expressed satisfaction with the intervention and stated that the information was helpful. CONCLUSION Delivery of a telephone-based intervention appears feasible. All family caregivers who began the program completed the four education modules. Future studies evaluating the effectiveness of the educational program should include a control group.
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Affiliation(s)
- Margaret J Bull
- College of Nursing, Marquette University, Milwaukee, Wisconsin
| | - Lesley Boaz
- College of Nursing, Marquette University, Milwaukee, Wisconsin
| | - Mehdi Maadooliat
- Department of Mathematics, Statistics and Computer Science, Marquette University, Milwaukee, Wisconsin
| | - Mary E Hagle
- Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin
| | - Lynn Gettrust
- Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin
| | | | | | - Jane S Saczynski
- Department of Epidemiology, Northeastern University, Boston, Massachusetts
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Jones RN, Marcantonio ER, Saczynski JS, Tommet D, Gross AL, Travison TG, Alsop DC, Schmitt EM, Fong TG, Cizginer S, Shafi MM, Pascual-Leone A, Inouye SK. Preoperative Cognitive Performance Dominates Risk for Delirium Among Older Adults. J Geriatr Psychiatry Neurol 2016; 29:320-327. [PMID: 27647793 PMCID: PMC5357583 DOI: 10.1177/0891988716666380] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Cognitive impairment is a well-recognized risk factor for delirium. Our goal was to determine whether the level of cognitive performance across the nondemented cognitive ability spectrum is correlated with delirium risk and to gauge the importance of cognition relative to other known risk factors for delirium. METHODS The Successful Aging after Elective Surgery study enrolled 566 adults aged ≥70 years scheduled for major surgery. Patients were assessed preoperatively and daily during hospitalization for the occurrence of delirium using the Confusion Assessment Method. Cognitive function was assessed preoperatively with an 11-test neuropsychological battery combined into a composite score for general cognitive performance (GCP). We examined the risk for delirium attributable to GCP, as well as demographic factors, vocabulary ability, and informant-rated cognitive decline, and compared the strength of association with risk factors identified in a previously published delirium prediction rule for delirium. RESULTS Delirium occurred in 135 (24%) patients. Lower GCP score was strongly and linearly predictive of delirium risk (relative risk = 2.0 per each half standard deviation difference in GCP score, 95% confidence interval, 1.5-2.5). This effect was not attenuated by statistical adjustment for demographics, vocabulary ability, and informant-rated cognitive decline. The effect was stronger than, and largely independent from, both standard delirium risk factors and comorbidity. CONCLUSION Risk of delirium is linearly and strongly related to presurgical cognitive performance level even at levels above the population median, which would be considered unimpaired.
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Affiliation(s)
| | | | | | | | | | | | - David C Alsop
- 2 Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | - Tamara G Fong
- 2 Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | - Mouhsin M Shafi
- 2 Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | - Sharon K Inouye
- 2 Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA
- 5 Hebrew SeniorLife, Boston, MA, USA
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Huang W, FitzGerald G, Goldberg RJ, Gore J, McManus RH, Awad H, Waring ME, Allison J, Saczynski JS, Kiefe CI, Fox KAA, Anderson FA, McManus DD. Performance of the GRACE Risk Score 2.0 Simplified Algorithm for Predicting 1-Year Death After Hospitalization for an Acute Coronary Syndrome in a Contemporary Multiracial Cohort. Am J Cardiol 2016; 118:1105-1110. [PMID: 27561191 DOI: 10.1016/j.amjcard.2016.07.029] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [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: 04/29/2016] [Revised: 07/10/2016] [Accepted: 07/10/2016] [Indexed: 12/22/2022]
Abstract
The GRACE Risk Score is a well-validated tool for estimating short- and long-term risk in acute coronary syndrome (ACS). GRACE Risk Score 2.0 substitutes several variables that may be unavailable to clinicians and, thus, limit use of the GRACE Risk Score. GRACE Risk Score 2.0 performed well in the original GRACE cohort. We sought to validate its performance in a contemporary multiracial ACS cohort, in particular in black patients with ACS. We evaluated the performance of the GRACE Risk Score 2.0 simplified algorithm for predicting 1-year mortality in 2,131 participants in Transitions, Risks, and Actions in Coronary Events Center for Outcomes Research and Education (TRACE-CORE), a multiracial cohort of patients discharged alive after an ACS in 2011 to 2013 from 6 hospitals in Massachusetts and Georgia. The median age of study participants was 61 years, 67% were men, and 16% were black. Half (51%) of the patients experienced a non-ST-segment elevation myocardial infarction (NSTEMI) and 18% STEMI. Eighty patients (3.8%) died within 12 months of discharge. The GRACE Risk Score 2.0 simplified algorithm demonstrated excellent model discrimination for predicting 1-year mortality after hospital discharge in the TRACE-CORE cohort (c-index = 0.77). The c-index was 0.94 in patients with STEMI, 0.78 in those with NSTEMI, and 0.87 in black patients with ACS. In conclusion, the GRACE Risk Score 2.0 simplified algorithm for predicting 1-year mortality exhibited excellent model discrimination across the spectrum of ACS types and racial/ethnic subgroups and, thus, may be a helpful tool to guide routine clinical care for patients with ACS.
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Affiliation(s)
- Wei Huang
- Center for Outcomes Research, Department of Surgery, University of Massachusetts Medical School, Worcester, Massachusetts.
| | - Gordon FitzGerald
- Center for Outcomes Research, Department of Surgery, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Robert J Goldberg
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Joel Gore
- Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Richard H McManus
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Hamza Awad
- Department of Community Medicine, Mercer University School of Medicine, Macon, Georgia
| | - Molly E Waring
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Jeroan Allison
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Jane S Saczynski
- Department of Pharmacy and Health Systems Sciences, Northeastern University, Boston, Massachusetts
| | - Catarina I Kiefe
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Keith A A Fox
- Center for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Frederick A Anderson
- Center for Outcomes Research, Department of Surgery, University of Massachusetts Medical School, Worcester, Massachusetts
| | - David D McManus
- Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
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Iadecola C, Yaffe K, Biller J, Bratzke LC, Faraci FM, Gorelick PB, Gulati M, Kamel H, Knopman DS, Launer LJ, Saczynski JS, Seshadri S, Zeki Al Hazzouri A. Impact of Hypertension on Cognitive Function: A Scientific Statement From the American Heart Association. Hypertension 2016; 68:e67-e94. [PMID: 27977393 DOI: 10.1161/hyp.0000000000000053] [Citation(s) in RCA: 404] [Impact Index Per Article: 50.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Age-related dementia, most commonly caused by Alzheimer disease or cerebrovascular factors (vascular dementia), is a major public health threat. Chronic arterial hypertension is a well-established risk factor for both types of dementia, but the link between hypertension and its treatment and cognition remains poorly understood. In this scientific statement, a multidisciplinary team of experts examines the impact of hypertension on cognition to assess the state of the knowledge, to identify gaps, and to provide future directions. METHODS Authors with relevant expertise were selected to contribute to this statement in accordance with the American Heart Association conflict-of-interest management policy. Panel members were assigned topics relevant to their areas of expertise, reviewed the literature, and summarized the available data. RESULTS Hypertension disrupts the structure and function of cerebral blood vessels, leads to ischemic damage of white matter regions critical for cognitive function, and may promote Alzheimer pathology. There is strong evidence of a deleterious influence of midlife hypertension on late-life cognitive function, but the cognitive impact of late-life hypertension is less clear. Observational studies demonstrated a cumulative effect of hypertension on cerebrovascular damage, but evidence from clinical trials that antihypertensive treatment improves cognition is not conclusive. CONCLUSIONS After carefully reviewing the literature, the group concluded that there were insufficient data to make evidence-based recommendations. However, judicious treatment of hypertension, taking into account goals of care and individual characteristics (eg, age and comorbidities), seems justified to safeguard vascular health and, as a consequence, brain health.
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