Atrial fibrillation in the elderly: a risk factor beyond stroke.

Atrial fibrillation (AF) represents the most common arrhythmia worldwide and its prevalence exponentially increases with age. It is related to increased risk of ischemic stroke or systemic embolism, which determines a significant burden of morbidity and mortality, as widely documented in the literature. AF also constitutes a risk factor for other less investigated conditions, such as heart failure, pulmonary embolism, impairment in physical performance, reduced quality of life, development of disability, mood disorders and cognitive impairment up to dementia. In the elderly population, the management of AF and its complications is particularly complex due to the heterogeneity of the ageing process, the lack of specific evidence-based recommendations, as well as the high grade of comorbidity and disability characterizing the over 65 years aged people. In the present review, we aim to summarize the pieces of the most updated evidence on AF complications beyond stoke, mainly focusing on the elderly population.

Agreement of a Short Form of the Self-Administered Multidimensional Prognostic Index (SELFY-MPI-SF): A Useful Tool for the Self-Assessment of Frailty in Community-Dwelling Older People.

BACKGROUND: The Multidimensional Prognostic Index (MPI) is a comprehensive geriatric assessment (CGA)-based tool that has shown excellent accuracy in predicting negative health outcomes in older people. Recently, the self-administered version of MPI (SELFY-MPI) has been validated in a community-dwelling sample, revealing excellent agreement with the original MPI. In the SELFY-MPI, Gijon's social-familial evaluation scale (SFES) was used to assess socio-relational and economic aspects. Completion of the SELFY-MPI, however, requires a significant amount of time in people aged over 60 years, particularly to fill in the SFES scale. The aim of this study was to validate, in a sample of community-dwelling older people, a short-form version of the SELFY-MPI (SELFY-MPI-SF), in which the SFES scale was replaced by the "co-habitation status" domain, as in the original version of the MPI. METHODS: All participants included in the study completed both versions of the self-administered MPI, which share the following seven domains: 1) basic and 2) instrumental activities of daily living, 3) mobility, 4) cognition, 5) nutrition, 6) comorbidity, and 7) number of medications. Moreover, in the SELFY-MPI-SF, the 8th domain "co-habitation status" (ie living alone, with family or in a residential facility) replaced the SFES scale. The Bland-Altman methodology was applied in order to measure the agreement between the two instruments. Finally, the time to complete the SFES scale and the question on co-habitation was measured. RESULTS: The final study sample was composed of 129 participants (mean age=76.8 years, range=65-93 years, 64.3% women) were enrolled. The mean SELFY-MPI and SELFY-MPI-SF values were 0.221±0.196 and 0.246± 0.188, respectively. The mean difference was clinically irrelevant (-0.025±0.058). None of the 129 observations showed values outside the established 5% limits of agreement. The agreement between SELFY-MPI and SELFY-MPI-SF was excellent (k=0.762; rho=0.924, p<0.0001 for both). Stratified analyses of agreement among subgroups of participants of different ages did not show any significant differences between the two versions. Completion of the SFES required about 7 mins, on average, while the question on habitation status required about 10 s. CONCLUSION: The SELFY-MPI-SF showed strong agreement and precision when compared with the standard SELFY-MPI in people aged 65 and older and can therefore be successfully used as a quicker self-administered frailty instrument in community-dwelling older people.

Does comprehensive geriatric assessment improve the estimate of surgical risk in elderly patients? An Italian multicenter observational study.

BACKGROUND: The evaluation of surgical risk is crucial in elderly patients. At present, there is little evidence of the usefulness of comprehensive geriatric assessment (CGA) as a part of the overall assessment of surgical elderly patients. METHODS: We verified whether CGA associated with established surgical risk assessment tools is able to improve the prediction of postoperative morbidity and mortality in 377 elderly patients undergoing elective surgery. RESULTS: Overall mortality and morbidity were 2.4% and 19.9%, respectively. Multivariate analysis showed that impaired cognitive function (odds ratio [OR], 1.33; 95% confidence interval [CI], 1.15 to 4.22; P < .02) and higher Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (OR, 1.11; 95% CI, 1.00 to 1.23; P < .04) are predictive of mortality. Higher comorbidity is predictive of morbidity (OR, 2.12; 95% CI, 1.06 to 4.22; P < .03) and higher American Society of Anesthesiologists (OR, 2.18; 95% CI, 1.31 to 3.63; P < .001) and National Confidential Enquiry into Patient Outcome of Death score (OR, 2.03; 95% CI, 1.03 to 4.00; P < .04). CONCLUSIONS: In elective surgical elderly patients, the morbidity and mortality are low. The use of CGA improves the identification of elderly patients at higher risk of adverse events, independent of the surgical prognostic indices.

Autonomic dysfunction in Alzheimer's disease: tools for assessment and review of the literature.

Autonomic dysfunction is very common in patients with dementia, and its presence might also help in differential diagnosis among dementia subtypes. Various central nervous system structures affected in Alzheimer's disease are also implicated in autonomic nervous system regulation, and it has been hypothesized that the deficit in central cholinergic function observed in Alzheimer's disease could likely lead to autonomic dysfunction. Several feasible tests can be used in clinical practice for the assessment of parasympathetic and sympathetic functions, especially in terms of cardiovascular autonomic modulation. In this review, we describe the different tests available and the evidence from the literature which indicate a definite presence of autonomic dysfunction in dementia at various degrees. Importantly, the recognition of dysautonomia, besides possibly being an early marker of dementia, would help prevent the disabling complications which increase the risk of morbidity, institutionalization, and mortality in these individuals.

Instruments for geriatric assessment: new multidimensional assessment approaches.

During the last century the considerable increase in life expectancy has led to important demographic changes and, consequently, to new clinical scenarios. Nowadays, chronic conditions, comorbidities and socio-economic factors constitute a relevant health management issue. In particular, the definition of frail elderly individuals has proven to have a strong role in the identification of high-risk patients, their clinical management and prognosis. Reorganization of the medical system has been associated with the development of new instruments for clinical assessment, focused on clinical and socio-economic issues, resulting in a multidimensional geriatric assessment. A large number of approaches have been validated in different clinical settings and populations, until the development of multidimensional instruments demonstrated to have a crucial role in the identification of frail individuals and in their clinical management. Interestingly, some of these, such as the Multidimensional Prognostic Index (MPI), proved to play a relevant role in mortality risk stratification even in particular clinical settings such as chronic kidney disease.

Multidimensional Prognostic Index based on a comprehensive geriatric assessment predicts short-term mortality in older patients with heart failure.

BACKGROUND: Multidimensional impairment of older patients may influence the clinical outcome of diseases. The aim of this study was to evaluate whether a Multidimensional Prognostic Index (MPI) based on a comprehensive geriatric assessment predicts short-term mortality in older patients with heart failure. METHODS AND RESULTS: In this prospective study with a 1-month follow-up, 376 patients aged 65 and older with a diagnosis of heart failure were enrolled. A standardized comprehensive geriatric assessment that included information on functional (activities of daily living and instrumental activities of daily living), cognitive (Short Portable Mental Status Questionnaire), and nutritional status (Mini Nutritional Assessment), as well as on risk of pressure sore (Exton-Smith Scale), comorbidities (Cumulative Illness Rating Scale Index), medications, and social support network, was used to calculate the MPI for mortality using a previously validated algorithm. The New York Heart Association, the Enhanced Feedback for Effective Cardiac Treatment, and the Acute Decompensated Heart Failure National Registry regression model scores were also calculated. Higher MPI values were significantly associated with higher 30-day mortality, both in men (MPI-1, 2.8%; MPI-2, 15.3%; MPI-3, 47.4%; P=0.000) and women (MPI-1, 0%; MPI-2, 6.5%; MPI-3, 14.6%; P=0.011). The discrimination of the MPI was also good, with areas under the receiver operating characteristic curves (men: 0.83; 95% CI, 0.75 to 0.90; women: 0.80; 95% CI, 0.71 to 0.89) greater than receiver operating characteristic areas of New York Heart Association (men: 0.63; 95% CI, 0.57 to 0.69; P=0.015; women: 0.65; 95% CI, 0.55 to 0.75; P=0.064), Enhanced Feedback for Effective Cardiac Treatment (men: 0.69; 95% CI, 0.58 to 0.79; P=0.045; women: 0.71; 95% CI, 0.55 to 0.87; P=0.443), and Acute Decompensated Heart Failure National Registry scores (men: 0.65; 95% CI, 0.52 to 0.78; P=0.023; women: 0.67; 95% CI, 0.49 to 0.83, P=0.171). CONCLUSIONS: The MPI, calculated from information collected in a standardized comprehensive geriatric assessment, is useful to estimate the risk of 1-month mortality in older patients with heart failure.