Health behavior outcomes in stroke survivors prescribed wearables for atrial fibrillation detection stratified by age

BACKGROUND

Smartwatches have become readily accessible tools for detecting atrial fibrillation (AF). There remains limited data on how they affect psychosocial outcomes and engagement in older adults. We examine the health behavior outcomes of stroke survivors prescribed smartwatches for AF detection stratified by age.

METHODS

We analyzed data from the Pulsewatch study, a randomized controlled trial that enrolled patients (≥ 50 years) with a history of stroke or transient ischemic attack and CHA2DS2-VASc ≥ 2. Intervention participants were equipped with a cardiac patch monitor and a smartwatch-app dyad, while control participants wore the cardiac patch monitor for up to 44 days. We evaluated health behavior parameters using standardized tools, including the Consumer Health Activation Index, the Generalized Anxiety Disorder questionnaire, the 12-Item Short Form Health Survey, and wear time of participants categorized into three age groups: Group 1 (ages 50-60), Group 2 (ages 61-69), and Group 3 (ages 70-87). We performed statistical analysis using a mixed-effects repeated measures linear regression model to examine differences amongst age groups.

RESULTS

Comparative analysis between Groups 1, 2 and 3 revealed no significant differences in anxiety, patient activation, perception of physical health and wear time. The use of smartwatch technology was associated with a decrease in perception of mental health for Group 2 compared to Group 1 (β = -3.29, P = 0.046).

CONCLUSION

Stroke survivors demonstrated a willingness to use smartwatches for AF monitoring. Importantly, among these study participants, the majority did not experience negative health behavior outcomes or decreased engagement as age increased.

Technology engagement is associated with higher perceived physical well-being in stroke patients prescribed smartwatches for atrial fibrillation detection

Background

Increasing ownership of smartphones among Americans provides an opportunity to use these technologies to manage medical conditions. We examine the influence of baseline smartwatch ownership on changes in self-reported anxiety, patient engagement, and health-related quality of life when prescribed smartwatch for AF detection.

Method

We performed a post-hoc secondary analysis of the Pulsewatch study (NCT03761394), a clinical trial in which 120 participants were randomized to receive a smartwatch-smartphone app dyad and ECG patch monitor compared to an ECG patch monitor alone to establish the accuracy of the smartwatch-smartphone app dyad for detection of AF. At baseline, 14 days, and 44 days, participants completed the Generalized Anxiety Disorder-7 survey, the Health Survey SF-12, and the Consumer Health Activation Index. Mixed-effects linear regression models using repeated measures with anxiety, patient activation, physical and mental health status as outcomes were used to examine their association with smartwatch ownership at baseline.

Results

Ninety-six participants, primarily White with high income and tertiary education, were randomized to receive a study smartwatch-smartphone dyad. Twenty-four (25%) participants previously owned a smartwatch. Compared to those who did not previously own a smartwatch, smartwatch owners reported significant greater increase in their self-reported physical health (β = 5.07, P < 0.05), no differences in anxiety (β = 0.92, P = 0.33), mental health (β = -2.42, P = 0.16), or patient activation (β = 1.86, P = 0.54).

Conclusions

Participants who own a smartwatch at baseline reported a greater positive change in self-reported physical health, but not in anxiety, patient activation, or self-reported mental health over the study period.

Anxiety, patient activation, and quality of life among stroke survivors prescribed smartwatches for atrial fibrillation monitoring

Background

The detection of atrial fibrillation (AF) in stroke survivors is critical to decreasing the risk of recurrent stroke. Smartwatches have emerged as a convenient and accurate means of AF diagnosis; however, the impact on critical patient-reported outcomes, including anxiety, engagement, and quality of life, remains ill defined.

Objectives

To examine the association between smartwatch prescription for AF detection and the patient-reported outcomes of anxiety, patient activation, and self-reported health.

Methods

We used data from the Pulsewatch trial, a 2-phase randomized controlled trial that included participants aged 50 years or older with a history of ischemic stroke. Participants were randomized to use either a proprietary smartphone-smartwatch app for 30 days of AF monitoring or no cardiac rhythm monitoring. Validated surveys were deployed before and after the 30-day study period to assess anxiety, patient activation, and self-rated physical and mental health. Logistic regression and generalized estimation equations were used to examine the association between smartwatch prescription for AF monitoring and changes in the patient-reported outcomes.

Results

A total of 110 participants (mean age 64 years, 41% female, 91% non-Hispanic White) were studied. Seventy percent of intervention participants were novice smartwatch users, as opposed to 84% of controls, and there was no significant difference in baseline rates of anxiety, activation, or self-rated health between the 2 groups. The incidence of new AF among smartwatch users was 6%. Participants who were prescribed smartwatches did not have a statistically significant change in anxiety, activation, or self-reported health as compared to those who were not prescribed smartwatches. The results held even after removing participants who received an AF alert on the watch.

Conclusion

The prescription of smartwatches to stroke survivors for AF monitoring does not adversely affect key patient-reported outcomes. Further research is needed to better inform the successful deployment of smartwatches in clinical practice.

False Atrial Fibrillation Alerts from Smartwatches are Associated with Decreased Perceived Physical Well-being and Confidence in Chronic Symptoms Management

Wrist-based wearables have been FDA approved for AF detection. However, the health behavior impact of false AF alerts from wearables on older patients at high risk for AF are not known. In this work, we analyzed data from the Pulsewatch (NCT03761394) study, which randomized patients (≥50 years) with history of stroke or transient ischemic attack to wear a patch monitor and a smartwatch linked to a smartphone running the Pulsewatch application vs to only the cardiac patch monitor over 14 days. At baseline and 14 days, participants completed validated instruments to assess for anxiety, patient activation, perceived mental and physical health, chronic symptom management self-efficacy, and medicine adherence. We employed linear regression to examine associations between false AF alerts with change in patient-reported outcomes. Receipt of false AF alerts was related to a dose-dependent decline in self-perceived physical health and levels of disease self-management. We developed a novel convolutional denoising autoencoder (CDA) to remove motion and noise artifacts in photoplethysmography (PPG) segments to optimize AF detection, which substantially reduced the number of false alerts. A promising approach to avoid negative impact of false alerts is to employ artificial intelligence driven algorithms to improve accuracy.

Patient activation and health-related quality-of-life in association with smartwatch alerts for atrial fibrillation detection

Background

Smartwatches with various alert systems are becoming increasingly popular in the detection of atrial fibrillation (AF) post stroke, however their impact on psychological well-being remains unknown.

Purpose

Assess the association between smartwatch alerts for detected atrial fibrillation in older stroke survivors and patient activation as well as health-related quality-of-life.

Methods

Data were used from the Pulsewatch study, a multiphase, randomized controlled trial, which enrolled older adults (≥50 years of age) from the UMass Memorial Health System with history of a stroke and no contraindications to anticoagulation, who were given a smartwatch for AF detection. In Phase I, participants were randomized 3:1 (intervention:control) to receive a smartwatch/smartphone pair and an FDA-approved cardiac patch monitor or only the patch (control) to monitor for AF for 14 days. In Phase II, participants were re-randomized 1:1, with the intervention group being offered the smartwatch/smartphone pair for an extra 30 days. Participants were grouped into those receiving at least one alert of a possible abnormal rhythm versus those who did not receive any alerts from their smartwatch. At baseline, 14 days, and 44 days the Consumer Health Activation Index was used to assess patient activation and the Physical and Mental Component Summary of Short-Form Health Survey were utilized to evaluate physical and mental health-related quality-of-life, respectively. Mixed-effects repeated measures linear regression models were used to examine changes in patient activation and physical and mental health-related quality-of-life, in relation to alerts, adjusting for confounding variables including age, sex, race, history of arrhythmias, history of congestive heart failure, history of coronary artery disease, baseline depression, and baseline cognitive impairment, over the study period.

Results

94 participants (64.6±9.1 years of age, 87.2% non-Hispanic white, and 43.6% female) were included in the analysis; 16 of whom received at least one alert. Specifically, twelve participants received 1 to 3 alerts, three participants received 11 to 18, and one participant received 226. In fully adjusted models, receiving alerts was not associated with changes in patient activation or mental health-related quality-of-life (β −1.70, p-value 0.60 and β 2.85, p-value 0.09 respectively), but was associated with a significant reduction in physical health-related quality-of-life (β −4.67, p-value 0.04).

Conclusions

In a cohort of older stroke survivors who wore smartwatches for up to 44 days, reception of alerts was not significantly associated with changes in patient activation or mental health-related quality-of-life but was significantly related to a decline in physical health-related quality-of-life. Further studies are necessary to explore the use of smartwatches in AF screening and their impact on psychological health and quality-of-life.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): R01HL137734 from the National Heart, Lung, and Blood Institute

Cost Reduction Behaviors and Cost-Related Medication Nonadherence in Older Adults with Atrial Fibrillation

While factors such as forgetfulness may result in medication nonadherence, 2.7 million older adults in the US experience cost-related nonadherence (CRN). Limited research has explored CRN and associated cost-reduction behaviors (CRB) in older adults with atrial fibrillation. The objectives of this study were to 1) describe the prevalence of CRN, CRB and spending less on basic needs to afford medication and 2) examine factors associated with CRB among older adults with atrial fibrillation. Data were drawn from the Systematic Assessment of Geriatric Elements in Atrial Fibrillation (SAGE-AF), a prospective cohort of older adults with atrial fibrillation (&gt;65 years). Using a self-administered survey, all participants completed a validated CRN measure. Chi-square and t-tests were used to evaluate differences in participant characteristics across CRB and significant characteristics (p&lt;0.05) were entered into a logistic regression model. Participants (N=1244) were on average 76 years and 49% were female. Among all participants, 4.2% reported CRN; 69.1% reported CRB; and 5.9% reported spending less on basic needs. Compared to participants who did not engage in CRB, participants who engaged in CRB were less likely to be cognitively impaired and more likely to be a race/ethnicity other than non-Hispanic white; have Medicare insurance; and have comorbidities. CRB were common among older adults with atrial fibrillation and was associated with in-tact cognitive function, the presence of medical comorbidities and non-White race. Clinicians might consider providing patients with cognitive impairment additional support such as patient assistance programs or referrals to pharmacists for medication therapy management to assist with CRB.

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

OBJECTIVE

To examine the extent of, and factors associated with, patient engagement in shared decision-making (SDM) for stroke prevention among patients with atrial fibrillation (AF).

METHODS

We used data from the Systematic Assessment of Geriatric Elements-Atrial Fibrillation study which includes older ( ≥65 years) patients with AF and a CHA2DS2-VASc≥2. Participants reported engagement in SDM by answering whether they actively participated in choosing to take an oral anticoagulant (OAC) for their condition. Multiple logistic regression was used to assess associations between sociodemographic, clinical, geriatric, and psychosocial factors and patient engagement in SDM.

RESULTS

A total of 807 participants (mean age 75 years; 48% female) on an OAC were studied. Of these, 61% engaged in SDM. Older participants (≥80 years) and those cognitively impaired were less likely to engage in SDM, while those very knowledgeable of their AF associated stroke risk were more likely to do so than respective comparison groups.

CONCLUSIONS

A considerable proportion of older adults with AF did not engage in SDM for stroke prevention with older patients and those cognitively impaired less likely to do so. Clinicians should identify patients who are less likely to engage in SDM, promote patient engagement, and foster better patient-provider communication which may enhance long-term patient outcomes.

Sociodemographic, behavioral, and clinical factors associated with low atrial fibrillation knowledge among older adults with atrial fibrillation: The SAGE-AF study

BACKGROUND

Management of AF requires patient engagement in disease management which requires adequate knowledge about AF.

OBJECTIVE

To identify the patient characteristics associated with low AF knowledge among older adults with AF.

METHODS

The SAGE-AF cohort enrolled adults aged ≥65 diagnosed with AF in 2016-2018. Patient characteristics associated with low AF knowledge (<6/8 JAKQ items correct) were examined using multivariable adjusted logistic regression models.

RESULTS

Participants (N = 950) were on average 74 years old (SD: 6.7), 50 % female, and 87 % non-Hispanic white. The average JAKQ score was 68.7 (SD: 17.1), and 78 % had low AF knowledge. Participants aged ≥ 75 (OR: 1.55, 95 % CI: 1.03, 2.33), without a college degree (OR: 0.46, 95 % CI: 0.32, 0.65), cognitively impaired (OR: 1.72, 95 % CI: 1.15, 2.58), with a history of anxiety (OR: 1.76, 95 % CI: 1.09, 2.83), myocardial infarction (OR: 1.82, 95 % CI: 1.08, 3.07), and heart failure (OR: 1.84, 95 % CI: 1.16, 2.91) were more likely to have low AF knowledge.

PRACTICE IMPLICATIONS

Characteristics available in the electronic medical record may identify patients at risk for low AF knowledge. Formal assessment of AF knowledge may identify areas of weakness and allow for targeted education.

Systematic Review of Risk and Protective Factors for Revictimization After Child Sexual Abuse

Child sexual abuse (CSA) is a widespread public health problem in the United States. It has been associated with multiple long-term deleterious outcomes including revictimization in adulthood. This systematic review of 25 studies synthesizes research examining possible risk and protective factors that might explain the established link between CSA and future victimizations. Specific risk factors identified included co-occurring maltreatment in the home, risky sexual behavior (particularly in adolescence), post-traumatic stress disorder, emotion dysregulation, and other maladaptive coping strategies. Only one protective factor was identified: perceived parental care. The review also revealed considerable variability in definitions and measurement of both CSA and adult victimization, particularly in terms of how researchers conceptualized age. Many of the studies were limited in generalizability by including only college-age women. These findings have clinical and research implications. Public health interventions working to prevent revictimization among CSA survivors can utilize these findings when designing programs. For researchers, the results highlight the need for standardized definitions of both CSA and revictimization, for well-validated and consistent measurement, and for inclusion of additional population groups in future research.

Family Identification of Delirium in the Emergency Department in Patients With and Without Dementia: Validity of the Family Confusion Assessment Method (FAM-CAM)

OBJECTIVE

To examine the ability of the family-rated Family Confusion Assessment Method (FAM-CAM) to identify delirium in the emergency department (ED) among patients with and without dementia, as compared to the reference-standard Confusion Assessment Method (CAM).

DESIGN

Validation study.

SETTING

Urban academic ED.

PARTICIPANTS

Dyads of ED patients, aged 70 years and older, and their family caregivers (N = 108 dyads).

MEASUREMENTS

A trained reference standard interviewer performed a cognitive screen, delirium symptom assessment, and scored the CAM. The caregiver self-administered the FAM-CAM. Dementia was assessed using the Informant Questionnaire on Cognitive Decline in the Elderly and the medical record. For concurrent validity, performance of the FAM-CAM was compared to the CAM. For predictive validity, clinical outcomes (ED visits, hospitalization, and mortality) over 6 months were compared in FAM-CAM positive and negative patients, controlling for age, sex, comorbidity, and cognitive status.

RESULTS

Among the 108 patients, 30 (28%) were CAM positive for delirium and 58 (54%) presented with dementia. The FAM-CAM had a specificity of 83% and a negative predictive value of 83%. Most false negatives (n = 9 of 13, 69%) were due to caregivers not identifying the inattention criteria for delirium on the FAM-CAM. In patients with dementia, sensitivity was higher than in patients without (61% vs 43%). In adjusted models, a hospitalization in the following 6 months was more than three times as likely in FAM-CAM positive compared to negative patients (odds ratio = 3.4; 95% confidence interval = 1.2-9.3).

CONCLUSIONS

Among patients with and without dementia, the FAM-CAM shows qualities that are important in the ED setting for identification of delirium. Using the FAM-CAM as part of a systematic screening strategy for the ED, in which families' assessments could supplement healthcare professionals' assessments, is promising. J Am Geriatr Soc 68:983-990, 2020.

Geriatric Conditions and Prescription of Vitamin K Antagonists vs. Direct Oral Anticoagulants Among Older Patients With Atrial Fibrillation: SAGE-AF

Background: Geriatric conditions are common among patients with atrial fibrillation (AF) and relate to complications of oral anticoagulation (OAC).

Objective: To examine the prevalence of geriatric conditions among older patients with AF on OAC and relate type of OAC to geriatric conditions.

Methods: Participants had a diagnosis of AF, were aged ≥65 years, CHA₂DS₂VASC ≥ 2, and had no OAC contraindications. Participants completed a 6-component geriatric assessment that included validated measures of frailty (CHS Frailty Scale), cognitive function (MoCA), social support (MOS), depressive symptoms (PHQ9), vision, and hearing. Type of OAC prescribed was documented in medical records.

Results: 86% of participants were prescribed an OAC. These participants were on average aged 75.7 (SD: 7.1) years, 49% were women, two thirds were frail or pre-frail, and 44% received a DOAC. DOAC users were younger, had lower CHA₂DS₂VASC and HAS-BLED scores, and were less likely to be frail. In Massachusetts, pre-frailty was associated with a significantly lower odds of DOAC vs. VKA use (OR = 0.64, 95%CI 0.45, 0.91). Pre-frailty (OR = 0.33, 95%CI 0.18–0.59) and social isolation (OR = 0.38, 95%CI 0.14–0.99) were associated with lower odds of DOAC receipt in patients aged 75 years or older. Social isolation was associated with higher odds of DOAC use (OR = 2.13, 95%CI 1.05–4.29) in patients aged 65–74 years.

Conclusions: Geriatric conditions were common and related to type of OAC prescribed, differentially by age group. Research is needed to evaluate whether a geriatric examination can be used clinically to better inform OAC decision-making in older patients with AF.

Physical, cognitive, and psychosocial conditions in relation to anticoagulation satisfaction among elderly adults with atrial fibrillation: The SAGE-AF study

BACKGROUND

Successful anticoagulation is critical for stroke prevention in adults with atrial fibrillation (AF). Anticoagulation satisfaction is a key indicator of treatment success. While physical, cognitive, and psychosocial limitations are common in elderly AF patients, their associations with anticoagulation satisfaction are unknown.

OBJECTIVE

Examine whether anticoagulation satisfaction differs among AF patients with and without physical, cognitive, and psychosocial conditions.

METHODS

The study comprised AF patients greater than or equal to 65 years old who were prescribed an oral anticoagulant (warfarin 57%; direct oral anticoagulant [DOAC] 43%). Frailty, cognitive function, social support, depressive symptoms, vision, hearing, and anxiety were assessed using validated measures. Anticoagulation satisfaction was measured using the anticlot treatment scale.

RESULTS

Participants (n = 1037, 50% female) were on average 76 years old. The following conditions were prevalent: frailty (14%), cognitive impairment (42%), social isolation (13%), vision impairment (35%), hearing impairment (36%), depression (29%), and anxiety (24%). Average anticlot treatment burden scale was 55 out of 60 (lower burden scales indicating higher perceived burden). Patients with high perceived burden were older, more likely to be female, and receive warfarin. After adjusting for confounders, visual impairment (adjusted odds ratio [95% confidence interval]: 1.7 [1.2-2.4]), depressive symptoms (2.4 [1.6-3.7]), and anxiety (1.8 [1.2-2.7]) were significantly associated with high perceived burden. Different conditions were associated with high perceived burden in warfarin vs DOAC users.

CONCLUSION

Physical, cognitive, and psychosocial limitations are prevalent and associated with high perceived anticoagulation burden among elderly AF adults. These conditions merit consideration in anticoagulation prescribing.

Accuracy and Usability of a Novel Algorithm for Detection of Irregular Pulse Using a Smartwatch Among Older Adults: Observational Study

BACKGROUND

Atrial fibrillation (AF) is often paroxysmal and minimally symptomatic, hindering its diagnosis. Smartwatches may enhance AF care by facilitating long-term, noninvasive monitoring.

OBJECTIVE

This study aimed to examine the accuracy and usability of arrhythmia discrimination using a smartwatch.

METHODS

A total of 40 adults presenting to a cardiology clinic wore a smartwatch and Holter monitor and performed scripted movements to simulate activities of daily living (ADLs). Participants' clinical and sociodemographic characteristics were abstracted from medical records. Participants completed a questionnaire assessing different domains of the device's usability. Pulse recordings were analyzed blindly using a real-time realizable algorithm and compared with gold-standard Holter monitoring.

RESULTS

The average age of participants was 71 (SD 8) years; most participants had AF risk factors and 23% (9/39) were in AF. About half of the participants owned smartphones, but none owned smartwatches. Participants wore the smartwatch for 42 (SD 14) min while generating motion noise to simulate ADLs. The algorithm determined 53 of the 314 30-second noise-free pulse segments as consistent with AF. Compared with the gold standard, the algorithm demonstrated excellent sensitivity (98.2%), specificity (98.1%), and accuracy (98.1%) for identifying irregular pulse. Two-thirds of participants considered the smartwatch highly usable. Younger age and prior cardioversion were associated with greater overall comfort and comfort with data privacy with using a smartwatch for rhythm monitoring, respectively.

CONCLUSIONS

A real-time realizable algorithm analyzing smartwatch pulse recordings demonstrated high accuracy for identifying pulse irregularities among older participants. Despite advanced age, lack of smartwatch familiarity, and high burden of comorbidities, participants found the smartwatch to be highly acceptable.

Abstract 209: Sex Differences in Characteristics, Symptoms, and Management of Geriatric Patients with Atrial Fibrillation: Insights from the SAGE-AF Study

Background: Data from previous studies that examined sex differences in the characteristics, clinical presentation, and management of patients with atrial fibrillation (AF) have been inconsistent.

Objective: To use data from a large contemporary cohort of older patients with AF to examine sex specific differences in baseline characteristics, symptoms, and management practices.

Methods: We used data from baseline interviews and the review of medical records of participants in the Systematic Assessment of Geriatric Elements in AF (SAGE-AF) study. Participants were ≥ 65 years old with AF and a CHA2DS2-VASc≥ 2.

Results: Of the 1244 participants, 49% were female. Women on average were slightly older (76.3 (7.4) vs. 74.8 (6.7) years, p<0.01), and less often had a history of coronary heart disease, diabetes, renal disease, dyslipidemia, smoking, or alcohol abuse, in comparison with men. Women reported higher rates of anxiety, depression, and frailty (27% vs. 20%, 34% vs. 23%, and 18% vs. 10%, respectively, p<0.01) when compared with men. Women had higher average CHA2DS2-VASc (4.9 (1.6) vs. 4.0 (1.5), p<0.01) but lower HAS-BLED (2.7 (1.0) vs. 3.0 (1.0), p<0.01) scores compared with men. Women more frequently reported AF-related symptoms of palpitations, irregular heartbeat, pause in heart activity, and dizziness (29% vs. 16%, 22% vs. 15%, 11% vs. 6%, and 25% vs. 19%, respectively, p<0.05) than men. Women were more likely to have paroxysmal AF (54% vs. 65%, p<0.01) than persistent AF (30% vs. 20%, p<0.01) than men. Approximately 85% of study participants received oral anticoagulants (OACs). There were no significant differences in either the rates of prescription of OACs or their classes between men and women. There were no sex differences in the choice of rate or rhythm control treatments by sex. Multivariable adjusted models showed that women were less frequently treated with cardioversion (OR=0.69, 95% CI: 0.54-0.90), pacemaker (OR= 0.73, 95% CI: 0.56-0.96), or an implanted defibrillator (OR= 0.32, 95% CI: 0.21-0.50) compared with men.

Conclusion: Women with AF were older, had more psychosocial but less comorbidities, and were more symptomatic than men. While no differences in the receipt of OACs were detected, women continue to be treated more conservatively with lower rates of receipt of interventions than men.

Impact of anxiety on the post-discharge outcomes of patients discharged from the hospital after an acute coronary syndrome

BACKGROUND

Symptoms of anxiety are highly prevalent among survivors of an acute coronary syndrome (ACS), but do not necessarily indicate an anxiety disorder. The extent to which symptoms of anxiety or a diagnosis of this condition impacts hospital readmission and post-discharge mortality among patients with an ACS remains unclear.

METHODS

We used data from 1909 patients discharged from six hospitals in Massachusetts and Georgia after an ACS. Moderate/severe symptoms of anxiety were defined based on responses to a Generalized Anxiety Disorder questionnaire during the patient's index hospitalization. The diagnosis of an anxiety disorder was based on review of hospital medical records. Multivariable adjusted Poisson regression and Cox proportional-hazards models were used to estimate the risk of 30-day hospital readmissions and 2-year total mortality.

RESULTS

The mean age of the study population was 61 years, two thirds were men, and 78% were non-Hispanic whites. In this population, 10.4% had a documented diagnosis of an anxiety disorder, 18.8% had moderate/severe symptoms of anxiety, and 70.8% had neither a diagnosis nor symptoms of anxiety. Neither a diagnosis of an anxiety disorder nor symptoms of anxiety were associated with 30-day all-cause or cardiovascular-related rehospitalizations. Patients with an anxiety disorder (multivariable adjusted HR = 1.95, 95%CI = 1.11-3.42) were at greatest risk for dying during the 2-year follow-up period.

CONCLUSIONS

We identified patients with an anxiety disorder as being at greater risk for dying after hospital discharge for an ACS. Interventions may be more appropriately targeted to those with a history of, rather than acute symptoms of, anxiety.

Social Activities, Incident Cardiovascular Disease, and Mortality

Objective: This study examined the relationships between social activities, incident cardiovascular disease (CVD), and non-CVD mortality among older adults in the United States. Method: Data from the Health and Retirement Study (2006-2010) were employed. Two measures of social engagement, volunteering and informal helping, along with two measures of social participation, attendance at religious services and social group meetings, were included. Mediation models for health behaviors were estimated. Results: Multinomial logistic regression models demonstrated that volunteering provided the most consistent results in terms of a lower risk of incident CVD and mortality. Furthermore, volunteering at higher time commitments is related to lower CVD incidence and death; informally helping others at a modest time commitment is related to lower risk of death only. Health behaviors mediated the relationships. Social participation was not related to either CVD or mortality. Discussion: Social activity is a modifiable behavior that may be considered a potential health intervention.

The modified Hospital Elder Life Program: adapting a complex intervention for feasibility and scalability in a surgical setting

The purpose of this article is to provide the rationale and methods for adapting the Hospital Elder Life Program (HELP). The HELP is a complex intervention that has been shown to reduce rates of delirium and functional decline. However, modification of the program may be required to meet local circumstances and specialized populations. We selected three key elements based on our prior work and the concept of shared risk factors and modified the HELP to include only three shared risk factors (functional, nutritional, and cognitive status) that were targeted by three nursing protocols: early mobilization, oral and nutritional assistance, and orienting communication. These protocols were adapted, refined, and pilot-tested for feasibility and efficacy. We hope by reporting the rationale and protocols for the modified HELP, we will advance the field for others adapting evidence-based, complex nursing interventions.

Risk factors for adverse outcomes by left ventricular ejection fraction in a contemporary heart failure population

BACKGROUND

Although heart failure (HF) is a syndrome with important differences in response to therapy by left ventricular ejection fraction (LVEF), existing risk stratification models typically group all HF patients together. The relative importance of common predictor variables for important clinical outcomes across strata of LVEF is relatively unknown.

METHODS AND RESULTS

We identified all members with HF between 2005 and 2008 from 4 integrated healthcare systems in the Cardiovascular Research Network. LVEF was categorized as preserved (LVEF ≥ 50% or normal), borderline (41%-49% or mildly reduced), and reduced (≤ 40% or moderately to severely reduced). We used Cox regression models to identify independent predictors of death and hospitalization by LVEF category. Among 30094 ambulatory adults with HF, mean age was 74 years and 46% were women. LVEF was preserved in 49.5%, borderline in 16.2%, and reduced in 34.3% of patients. During a median follow-up of 1.8 years (interquartile range, 0.8-3.1), 8060 (26.8%) patients died, 8108 (26.9%) were hospitalized for HF, and 20272 (67.4%) were hospitalized for any reason. In multivariable models, nearly all tested covariates performed similarly across LVEF strata for the outcome of death from any cause, as well as for HF-related and all-cause hospitalizations.

CONCLUSIONS

We found that in a large, diverse contemporary HF population, risk assessment was strikingly similar across all LVEF categories. These data suggest that, although many HF therapies are uniquely applied to patients with reduced LVEF, individual prognostic factor performance does not seem to be significantly related to level of left ventricular systolic function.

Abstract 247: Trends In The Use Of DNR Orders And Timing Of Writing Orders In Patients Hospitalized With Acute Myocardial Infarction

Aims: Several factors have led to an increase in the use of do-not-resuscitate (DNR) orders over the past decade, including the Patient Self-Determination Act, general increasing awareness of end-of-life decision making, and aging of the U.S. population. Although the characteristics of patients with DNR orders have been studied in the past, trends in the frequency and timing of DNR orders have not received much attention. The objectives of this population-based study were to examine recent (2001-2007) trends in the writing and timing of DNR orders in residents of a large central New England community hospitalized with acute myocardial infarction (AMI).

Methods: Data are from the Worcester Heart Attack Study, an ongoing longitudinal study examining long-term trends in the incidence, hospital, and post-discharge case fatality rates of AMI among residents of the Worcester (MA) metropolitan area. Clinical, demographic, and medical history data, including the use and timing (prior to hospitalization vs. during hospitalization) of DNR orders, were abstracted from the medical records of patients with confirmed AMI treated at all 11 medical centers in greater Worcester during the years under study.

Results: Approximately 25% (1,052 of 4,180) of patients hospitalized for AMI had a DNR order noted in their medical record. In both crude and multivariable adjusted analyses, there were no significant changes in the odds of having a DNR order written between 2001 (ref year) and 2007 (OR=1.17; 95% CI: 0.89-1.54). During this period, however, of patients who had a written DNR order, an increasing proportion had the DNR order prior to being admitted to the hospital (8.6% [25 of 292] in 2001; 54.8% [132 of 241] in 2007). In multivariable adjusted models, increasing age (≥ 85 years, OR=14.30; 95%CI10.00-20.45), history of heart failure (OR=1.67; 1.34-2.08) or stroke (OR=1.71; 1.33-2.20), and in-hospital death (OR=9.23; 6.74-12.63) were associated with having a DNR order. Only increasing age (>=85 years; OR=2.31, 1.05-5.09) and history of heart failure (OR=1.58; 1.16-2.15) were associated with having a DNR order in place prior to hospitalization.

Conclusions: The results of this community-wide study of greater Worcester residents hospitalized with AMI between 2001 and 2007 suggest that the overall use of DNR orders remained stable over this period. The timing of the writing of orders changed during this period, however, with a strong trend toward DNR orders being written prior to hospitalization for AMI. We found that this increasing proportion of DNR orders written prior to admission to the hospital was largely due to advanced age and complex medical history, which may indicate that a higher number of contacts with the medical system may increase the likelihood of having a DNR order. The changing landscape of the timing of writing DNR orders for individuals with heart disease, and the factors that result in early versus later writing of orders, deserves further investigation.

Are all caregivers created equal? Stress in caregivers to adults with and without dementia

OBJECTIVE

Caregiving for older adults is stressful; however, by treating caregivers as a homogenous group, it is possible that stress-related factors are misrepresented for some. This study of 349 elderly caregivers explored mediators of the caregiving / stress relationship for caregivers to adults with (n = 106), and without (n = 243) dementia.

METHODS

The sample was from the Caregiver Study of Osteoporotic Fractures (CG-SOF), ancillary to SOF, a four-site cohort of 9,704 women.

RESULTS

Stress was higher (p < .001) in dementia than nondementia caregivers (m = 19.85; 16.45). For caregivers overall, intensity and recipient problems were associated with stress but mediated through role captivity. However, relationships differed when stratified by recipient dementia status. Only recipient problems among nondementia caregivers was mediated through captivity.

DISCUSSION

Results confirm previous findings of lower stress among nondementia caregivers and suggest that different factors influence caregivers' appraisal of the situation, including their perception of stress, based on recipients' dementia status.