Effects of reminiscence therapy on anxiety and depression during acute hospitalization in older patients: Controlled study.

BACKGROUND/OBJECTIVES: Hospitalization due to acute illness in older patients is often associated with anxiety or depressive symptoms. In these circumstances, given that pharmacologic treatment should be avoided to reduce interactions with ongoing medication regimes, psychotherapy techniques should be considered. The purpose of this study was to evaluate the effectiveness of group reminiscence therapy (RT) on the reduction of anxiety and depressive symptoms in acutely hospitalized older patients. METHODS: Controlled and prospective study conducted on the Acute Geriatric Unit of a university hospital. Patients included in the intervention group (RT Group) attended a group session focused on RT, whereas those included in the control group (UC) received usual hospital care. Exclusion criteria were severe cognitive impairment, impossibility to mobilize, and clinical/hemodynamic instability. The intervention was based on a multi-task daily group session of reminiscence activities. The severity of anxiety (Hamilton Anxiety Rating Scale, HAM-A), depressive symptoms (15-item Geriatric Depression Scale, GDS-15), loneliness (ESTE-II social loneliness scale), and fear of death (Collet-Lester scale) was assessed at admission and discharge in both groups. RESULTS: The intervention was effective in reducing the proportion of patients with anxiety and depressive symptoms during hospitalization. The proportion of patients with moderate-severe anxiety at discharge was 32.1% in the UC and 13.4% in the RT Group (p < 0.001), whereas the proportion of patients with depressive symptoms at discharge was 49.1% in the UC and 19.5% in the RT Group (p < 0.001). The intervention was independently associated with benefits on anxiety levels (RR 2.45, 95% CI 1.83-3.28) and depression (RR 3.71, 95% CI 2.22-6.19) at discharge. No differences were found in loneliness or fear of death. CONCLUSIONS: A group reminiscence activity reduces the proportion of patients with anxiety and depressive symptoms during hospitalization for an acute disease. Absolute changes in both anxiety and depression scores, even though significant, were relatively small.

Functional trajectories associated with acute illness and hospitalization in oldest old patients: Impact on mortality.

Background: The literature pays low attention to functional changes during acute illness in older patients. Our main objectives were to separately describe the different functional changes occurring before and after hospital admission in oldest old medical patients, to investigate their association with mortality, and identify predictors associated with in-hospital failure to recover function. Methods: Secondary analysis of data from a prospective cohort study conducted in a tertiary teaching hospital. The study followed the STROBE criteria. The sample included 604 consecutive patients aged 65 or older hospitalized for acute illness, discharged alive, and not fully dependent at baseline. Activities of daily living measured at baseline, admission, and discharge were used to classify patients into four functional trajectories depending on whether they decline or remain stable between baseline and admission (prehospital) and whether they decline, remain stable, or recover baseline function between admission and discharge (in-hospital). Multivariate models were used to test the association between functional trajectories with mortality, and predictors for in-hospital recovery. Results: Functional trajectories were: "stable-stable" (18%); "decline-recovery" (18%); "decline-no recovery" (53%); "in-hospital decline" (11%). Prehospital decline occurred in 75% and 64% were discharged with worse function than baseline. "In-hospital decline" and "decline-no recovery" trajectories were independently associated with higher 6- and 12-month mortality. Extent of prehospital decline and dementia were predictors of failure to in-hospital recovery. Conclusion: In acutely ill older people, differentiating between prehospital and in-hospital functional changes has prognostic implications. Lack of functional regain at discharge is associated with higher mortality at 6- and 12-months.

Diagnosis, prevention, and management of delirium in the intensive cardiac care unit.

Delirium is a frequent complication in patients admitted to intensive cardiac care units (ICCU) with potentially severe consequences including increased risks of mortality, cognitive impairment and dependence at discharge, and longer times on mechanical ventilation and hospital stay. Delirium has been widely documented and studied in general intensive care units and in patients after cardiac surgery, but it has barely been studied in acute nonsurgical cardiac patients. Moreover, delirium (especially in its hypoactive form) is commonly misdiagnosed. We propose a protocol for delirium prevention and management in ICCUs. A daily comprehensive assessment to improve detection should be done using validated scales (ie, confusion assessment method). Preventive measures are particularly relevance and constitute the basis of treatment as well, acting on reversible risk factors, including environmental interventions, such as quiet time, sleep promotion, family support, communication, and adequate treatment of pain and dyspnea. Pharmacological prophylaxis is not indicated with the exception of patients at risk of withdrawal syndrome but should only be used in patients with confirmed delirium. Dexmedetomidine is the drug of choice in patients with severe agitation, and those weaning from invasive mechanical ventilation. As the complexity of ICCUs increases, clinical scenarios posing challenges for the management of delirium become more frequent. Efforts should be done to improve the identification of patients at risk during admission in order to establish preventive interventions to avoid this complication. Patient-centered protocols will increase the awareness of the healthcare professionals for better prevention and earlier diagnosis and will positively impact on prognosis.

Individual Responsiveness to Physical Exercise Intervention in Acutely Hospitalized Older Adults.

We analyzed inter-individual variability in response to exercise among acutely hospitalized oldest-old adults. In this ancillary analysis of a randomized controlled trial, 268 patients (mean age 88 years) were assigned to a control (n = 125, usual care) or intervention group (n = 143, supervised exercise, i.e., walking and rising from a chair [1-3 sessions/day]). Intervention group patients were categorized as responders, non-responders, or adverse responders (improved, no change, or impaired function in activities of daily living [ADL, Katz index] from hospital admission to discharge, respectively). We analyzed the association between responsiveness to exercise and variables assessed at baseline (2 weeks pre-admission), admission, during hospitalization, at discharge, and during a subsequent 3-month follow-up. An impaired ADL function and worse nutritional status at admission were associated to a greater responsiveness, whereas a better ADL function at admission, longer hospitalization and lower comorbidity index were associated with a poorer response (p < 0.05). Adverse responders had worse outcomes at discharge and during the follow-up (e.g., impaired physical performance and greater fall number) (p < 0.05). Although exercise intervention helps to prevent ADL function decline in hospitalized oldest-old people, a number of them-particularly those with a better functional/health status at admission and longer hospitalization-are at higher risk of being adverse responders, which can have negative short/middle-term consequences.

Prognostic impact of anemia according to frailty status in elderly patients with acute coronary syndromes.

AIMS: Anemia is associated with poorer outcomes in patients with acute coronary syndromes (ACS), but the magnitude of this association in elderly patients remains poorly understood. No study has assessed the prognostic impact of anemia according to frailty status in this setting. METHODS: The LONGEVO-SCA registry included unselected ACS patients aged at least 80 years. A geriatric assessment was performed during hospitalization, including frailty assessment using the FRAIL scale. Anemia was defined by the WHO criteria. We evaluated the impact of anemia on 6-month mortality according to the presence of frailty. RESULTS: A total of 517 patients were assessed. Mean age was 84.3 years, and a total of 236 patients (45.6%) had anemia. Patients with anemia had a higher prevalence of comorbidities and higher prevalence of frailty (30.6 vs. 22.3%, P = 0.007). A total of 60 patients (12.1%) died at 6 months [40 with anemia (17.5%) and 20 without anemia (7.5%), P = 0.001]. Anemia was independently associated with mortality at 6 months in the whole cohort (hazard ratio 2.28, 95% CI 1.13-457, P = 0.021). The association of anemia and mortality was different according to frailty status, being significant in patients without frailty (hazard ratio 3.94, 95% CI 1.84-8.45, P = 0.001), but not in frail patients (hazard ratio 1.17, 95% CI 0.53-2.57, P = 0.705), (P value for interaction = 0.035). CONCLUSION: A high proportion of elderly patients with ACS have anemia, leading to a worse prognosis in the whole cohort. The association between anemia and mortality was especially significant in robust patients, whereas the poorer prognosis in frail patients was not modified by the presence of anemia.

FRAIL Scale also Predicts Long-Term Outcomes in Older Patients With Acute Coronary Syndromes.

OBJECTIVES: No previous studies have assessed the role of the FRAIL scale in predicting long-term outcomes in older patients with acute coronary syndromes (ACS). DESIGN, SETTING AND PARTICIPANTS: The multicenter observational LONGEVO-SCA registry included unselected patients ≥80 years of age with ACS from 44 centers. A comprehensive geriatric assessment was performed during hospitalization. MEASURES: Frailty was measured by the FRAIL scale. For the purpose of this study, main outcome measured was mortality or readmission at 24 months. RESULTS: A total of 498 patients were included. Mean age was 84.3 years. A total of 198 patients (33.1%) were prefrail and 135 (27.1%) frail. Patients who were prefrail and frail had a higher degree of comorbidities, and higher prevalence of disability, cognitive impairment, and nutritional risk. A total of 165 out of 498 patients (33.1%) died, and 331 patients (66.7%) died or were readmitted at 24 months. Both prefrailty and frailty were associated with a higher mortality compared with robust patients (P < .001). The incidence of mortality or readmission was also higher in patients who were prefrail or frail (P < .001). After adjusting for potential confounders, the association between frailty and mortality or readmission remained significant (hazard ratio 1.28 for prefrailty and hazard ratio 1.96 for frailty, P < .001). The FRAIL scale showed an optimal ability for predicting mortality or readmission (area under the receiver operating characteristics curve 0.86, 95% confidence interval 0.83‒0.89). The area under the receiver operating characteristics curve from the Global Registry of Acute Coronary Events risk score was 0.89. No significant differences were observed between both AUC values (P = .163). CONCLUSIONS AND IMPLICATIONS: The FRAIL scale independently predicted long-term outcomes in older patients with ACS. The predictive ability of this scale was comparable to the strongly recommended Global Registry of Acute Coronary Events risk score. Frailty assessment is mandatory for improving risk prediction in these complex patients.

Most elderly patients hospitalized for heart failure lack the abilities needed to perform the tasks required for self-care: impact on outcomes.

AIM: To evaluate the abilities to perform essential tasks for heart failure (HF) self-management in elderly patients, and its influence on post-discharge prognosis. METHODS AND RESULTS: Overall, 415 patients ≥70 years old hospitalized for HF were included and followed during 1 year. The ability to perform six specific tasks (use of a scale, weight registration, diuretic identification, knowledge of salted foods, oedema identification, and treatment adjustment) was tested and distributed on terciles (T) of performance. Correlation with the self-administered questionnaire European HF Self-care Behaviour Scale (EHFScBS) was evaluated. The independent influence of self-care on 1-year mortality and readmission risks was calculated by Cox proportional hazards regression analysis. Mean age was 80.1 years. On average, patients could perform 2.9 ± 1.6 of self-care tasks, and only 5.3% could perform the six tasks correctly. Patients with previous HF self-care education had slight better performance (3.2 ± 1.6 vs 2.8 ± 1.6, P < 0.02). A weak correlation was found between EHFScBS and number of tasks correctly performed (r = -0.135; P = 0.006). One-year mortality in T1, T2, and T3 patients was 33.0%, 20.7%, and 14.1%, respectively (P = 0.002). Multivariable analysis showed T2 and T3 groups having a lower adjusted mortality risk compared with T1 [hazard ratio (HR) 0.58; 95% confidence interval (CI) 0.32-1.03; and HR 0.40; 95% CI 0.21-0.77, respectively], without differences in readmissions. CONCLUSION: Most elderly patients admitted for HF are unable to perform several essential tasks needed for HF self-care. Self-perception of care was poorly correlated with real ability, and poor self-care ability was associated with higher 1-year mortality risk.

Statin Treatment and Prognosis of Elderly Patients Discharged after Non-ST Segment Elevation Acute Coronary Syndrome.

BACKGROUND: Statins are recommended for secondary prevention. Our aims were to describe the proportion of very elderly patients receiving statins after non-ST segment elevation acute coronary syndrome (NST-ACS) and to determine the prognostic implications of statins use. METHODS: This prospective registry was performed in 44 hospitals that included patients ≥80 years discharged after a NST-ACS from April 2016 to September 2016. RESULTS: We included 523 patients, the mean age was 84.2 ± 4.0 years and 200 patients (38.2%) were women. Previous statin treatment was recorded in 282 patients (53.4%), and 135 (32.5%) had LDL cholesterol levels >2.6 mmol/L. Mean LDL cholesterol levels during admission were 2.3 ± 0.9 mmol/L. Statins were prescribed at discharge to 474 patients (90.6%). Compared with patients discharged on statins, those that did not receive statins were more often frail (22 [47.8%] vs. 114 [24.4%], p < 0.01) and underwent an invasive approach less frequently (30 [61.2%] vs. 374 [78.9%], p = 0.01). During a 6-month follow-up, 50 patients died (9.5%). There was a nonsignificant trend to higher mortality in patients not treated with statins (6 [15%] vs. 44 [9.6%], p = 0.30), but statins were not independently associated with lower mortality (hazard ratio [HR] 0.79; 95% confidence interval [CI] 0.30-2.11, p = 0.65), nor with a reduction in the combined endpoint mortality/hospitalizations (HR 0.89; 95% CI 0.52-1.55, p = 0.69). CONCLUSIONS: Although most octogenarians presenting a NST-ACS are already on statins before the episode, their LDL cholesterol is frequently >2.6 mmol/L. Octogenarians who do not receive statins have a high-risk profile, with significant frailty and comorbidity.

Mitral Regurgitation and Prognosis After Non-ST-Segment Elevation Myocardial Infarction in Very Old Patients.

BACKGROUND/OBJETCTIVES: Mitral regurgitation (MR)after an acute coronary syndrome is associated with a poor prognosis. However,the prognostic impact of MR in elderly patients with non-ST-segment elevation myocardialinfarction (NSTEMI) has not been well addressed. DESIGN: Prospective registry. SETTING AND PARTICIPANTS: The multicenter LONGEVO-SCA prospective registry included 532 unselected NSTEMI patients aged ≥80 years. MEASUREMENTS: MR was quantified using echocardiography during admission in 497 patients. They were classified in two groups: significant (moderate or severe) or not significant MR (absent or mild). We evaluated the impact of MR status on mortality or readmission at 6 months. RESULTS: Mean age was 84.3±4.1 years, and 308 (61.9%) were males. A total of 108 patients (21.7%) had significant MR. Compared with those without significant MR, they were older and showed worse baseline clinical status, with higher frailty, disability, and risk of malnutrition. They also had lower systolic blood pressure, higher heart rate, worse Killip class, lower left ventricular ejection fraction, and higher pulmonary pressure on admission, as well as more often new onset atrial fibrillation (all p values = 0.001). Patients with significant MR also had higher in-hospital mortality (4.6% vs. 1.3%, p = 0.04), longer hospital stay (median 8 [5-12] vs. 6 [4-10] days, p = 0.002), and higher mortality/readmission at 6 months (hazard ratio 1.54, 95% confidence interval 1.09-2.18, p = 0.015). However, after adjusting for potential confounders, this last association was not significant. CONCLUSIONS: Significant MR is seen in one fifth of octogenarians with NSTEMI. Patients with significant MR have a poor prognosis, mainly determined by their baseline clinical characteristics. J Am Geriatr Soc 67:1641-1648, 2019.

Clinical and prognostic implications of delirium in elderly patients with non-ST-segment elevation acute coronary syndromes.

BACKGROUND: Elderly patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS) may present delirium but its clinical relevance is unknown. This study aimed at determining the clinical associated factors, and prognostic implications of delirium in old-aged patients admitted for NSTE-ACS. METHODS: LONGEVO-SCA is a prospective multicenter registry including unselected patients with NSTE-ACS aged ≥ 80 years. Clinical variables and a complete geriatric evaluation were assessed during hospitalization. The association between delirium and 6-month mortality was assessed by a Cox regression model weighted for a propensity score including the potential confounding variables. We also analysed its association with 6-month bleeding and cognitive or functional decline. RESULTS: Among 527 patients included, thirty-seven (7%) patients presented delirium during the hospitalization. Delirium was more frequent in patients with dementia or depression and in those from nursing homes (27.0% vs. 3.1%, 24.3% vs. 11.6%, and 11.1% vs. 2.2%, respectively; all P < 0.05). Delirium was significantly associated with in-hospital infections (27.0% vs. 5.3%, P < 0.001) and usage of diuretics (70.3% vs. 49.8%, P = 0.02). Patients with delirium had longer hospitalizations [median 8.5 (5.5-14) vs. 6.0 (4.0-10) days, P = 0.02] and higher incidence of 6-month bleeding and mortality (32.3% vs. 10.0% and 24.3% vs. 10.8%, respectively; both P < 0.05) but similar cognitive or functional decline. Delirium was independently associated with 6-month mortality (HR = 1.47, 95% CI: 1.02-2.13, P = 0.04) and 6-month bleeding events (OR = 2.87; 95% CI: 1.98-4.16, P < 0.01). CONCLUSIONS: In-hospital delirium in elderly patients with NSTE-ACS is associated with some preventable risk factors and it is an independent predictor of 6-month mortality.

Effect of Barthel Index on the Risk of Thirty-Day Mortality in Patients With Acute Heart Failure Attending the Emergency Department: A Cohort Study of Nine Thousand Ninety-Eight Patients From the Epidemiology of Acute Heart Failure in Emergency Departments Registry.

STUDY OBJECTIVE: We assess the value of the Barthel Index (BI) in predicting 30-day mortality risk among patients with acute heart failure who are attending the emergency department (ED). METHODS: We selected 9,098 acute heart failure patients from the Acute Heart Failure in Emergency Departments registry who had BI score available both at baseline and the ED visit. Patients' data were collected from 41 Spanish hospitals during four 1- to 2-month periods between 2009 and 2016. Unadjusted and adjusted logistic regression models were used to assess the association between 30-day mortality and BI score. c Statistics were used to estimate their prognostic value. RESULTS: The mean baseline BI score was 79.4 (SD 24.6) and the mean ED BI score was 65.3 (SD 29.1). Acute functional decline (≥5-point decrease between baseline BI and ED BI score) was observed in 5,771 patients (53.4%). Within 30 days of the ED visit, 905 patients (9.9%) died. There was a steep inverse gradient in 30-day mortality risk for baseline BI and ED BI score. For instance, compared with BI score=100, a BI score of 50 to 55 doubled the mortality risk both at baseline and the ED visit. At the ED visit, a BI score of 0 to 5 carried a 5-fold increase in risk after adjustment for other risk predictors. In comparison with baseline BI score, ED BI score consistently provided greater discrimination. Neither baseline BI score nor the change in BI score from baseline to the ED visit added further prognostic value to the ED BI score. CONCLUSION: Functional status assessed by the BI score at the ED visit is a strong predictor of 30-day mortality in acute heart failure patients, with higher predictive value than baseline BI score and acute functional decline. Routine recording of BI score at the ED visit may help in decisionmaking and health care planning.

Diabetes mellitus, frailty and prognosis in very elderly patients with acute coronary syndromes.

BACKGROUND: The magnitude of the association between diabetes (DM) and outcomes in elderly patients with acute coronary syndromes (ACS) is controversial. No study assessed the prognostic impact of DM according to frailty status in these patients. METHODS: The LONGEVO-SCA registry included unselected ACS patients aged ≥ 80 years. Frailty was assessed by the FRAIL scale. We evaluated the impact of previous known DM on the incidence of death or readmission at 6 months according to status frailty by the Cox regression method. RESULTS: A total of 532 patients were included. Mean age was 84.3 years, and 212 patients (39.8%) had previous DM diagnosis. Patients with DM had more comorbidities and higher prevalence of frailty (33% vs 21.9%, p = 0.002). The incidence of death or readmission at 6 months was higher in patients with DM (HR 1.52, 95% CI 1.12-2.05, p 0.007), but after adjusting for potential confounders this association was not significant. The association between DM and outcomes was not significant in robust patients, but it was especially significant in patients with frailty [HR 1.72 (1.05-2.81), p = 0.030, p value for interaction = 0.049]. CONCLUSIONS: About 40% of elderly patients with ACS had previous known DM diagnosis. The association between DM and outcomes was different according to frailty status.

Octogenarian women with acute coronary syndrome present frailty and readmissions more frequently than men.

BACKGROUND: A worse prognosis has been reported among women with acute coronary syndrome compared to men. Our aim was to address the role of frailty and sex in the management and prognosis of elderly patients with non-ST-segment elevation acute coronary syndrome. METHODS: A prospective registry in 44 Spanish hospitals including patients aged 80 years and older with non-ST-segment elevation acute coronary syndrome. Frailty assessment was performed using the FRAIL scale. RESULTS: Of a total of 535 patients, 207 (38.7%) were women. Mean age was 84.8±4.0 years, similar in men and women. A prior history of coronary artery disease was more common in men (146, 44.9%) than in women (46, 22.2%), P<0.001. Frailty was less frequent in men (65, 20.2%) than in women (77, 37.8%), P<0.001. Female sex was an independent predictor of death/hospitalisation (hazard ratio (HR) 1.7, 95% confidence interval (CI) 1.1-2.4) and of hospitalisation at 6 months (HR 1.6, 95% CI 1.04-2.4). In men, compared to non-frail patients, both a prefrail status (HR 3.47, 95% CI 1.22-9.89) and frailty (HR 3.19, 95% CI 1.08-9.43) were independently associated with higher mortality. In women only frailty was independently associated with higher mortality (HR 5.68, 95% CI 1.91-16.18, compared to prefrailty or robustness). Frailty was associated with readmissions in men (HR 3.34, 95% CI 1.79-6.22) but not in women. CONCLUSIONS: In octogenarians with acute coronary syndrome female sex was independently associated with death/hospitalisation at 6 months. Frailty was more common in women and was a predictor of poor prognosis. In men prefrailty also predicted a poor prognosis.

Progressive edemas and generalized telangiectasia: A presentation of Intravascular B-cell Lymphoma.

Intravascular B-cell Lymphoma is a rare lymphoproliferative disorder with a none specific clinical presentation. The association of cutaneous telangiectasia-like lesions and elevated inflammatory markers should be guaranteed a skin biopsy.

Impact of Frailty on Mortality and Hospitalization in Chronic Heart Failure: A Systematic Review and Meta-Analysis.

Background Although frailty has been associated with increased risks for hospitalization and mortality in chronic heart failure, the precise average effect remains uncertain. We performed a systematic review and meta-analysis to summarize the hazards for mortality and incident hospitalization in patients with heart failure and frailty compared with those without frailty and explored the heterogeneity underlying the effect size estimates. Methods and Results MEDLINE , EMBASE, and Cochrane databases were queried for articles published between January 1966 and March 2018. Predefined selection criteria were used. Hazard ratios ( HRs ) were pooled for meta-analyses, and where odds ratios were used previously, original data were recalculated for HR . Overlapping data were consolidated, and only unique data points were used. Study quality and bias were assessed. Eight studies were included for mortality (2645 patients), and 6 studies were included for incident hospitalization (2541 patients) during a median follow-up of 1.82 and 1.12 years, respectively. Frailty was significantly associated with an increased hazard for mortality ( HR , 1.54; 95% confidence interval, 1.34-1.75; P<0.001) and incident hospitalization ( HR , 1.56; 95% confidence interval, 1.36-1.78; P<0.001) in chronic heart failure. The Fried phenotype estimated a 16.9% larger effect size than the combined Fried/non-Fried frailty assessment for the end point of mortality ( HR , 1.80; 95% confidence interval, 1.41-2.28; P<0.001), but not for hospitalization ( HR , 1.57; 95% confidence interval, 1.30-1.89; P<0.001). Study heterogeneity was found to be low (I2=0%), and high quality of studies was verified by the Newcastle-Ottawa scale. Conclusions Overall, the presence of frailty in chronic heart failure is associated with an increased hazard for death and hospitalization by ≈1.5-fold.

Invasive strategy and frailty in very elderly patients with acute coronary syndromes.

AIMS: Current guidelines recommend an early invasive strategy in patients with non-ST-segment elevation acute coronary syndromes (NSTEACS). The role of an invasive strategy in frail elderly patients remains controversial. The aim of this substudy was to assess the impact of an invasive strategy on outcomes according to the degree of frailty in these patients. METHODS AND RESULTS: The LONGEVO-SCA registry included unselected NSTEACS patients aged ≥80 years. A geriatric assessment, including frailty, was performed during hospitalisation. During the admission, we evaluated the impact of an invasive strategy on the incidence of cardiac death, reinfarction or new revascularisation at six months. From 531 patients included, 145 (27.3%) were frail. Mean age was 84.3 years. Most patients underwent an invasive strategy (407/531, 76.6%). Patients undergoing an invasive strategy were younger and had a lower proportion of frailty (23.3% vs. 40.3%, p<0.001). The incidence of cardiac events was more common in patients managed conservatively, after adjusting for confounding factors (sub-hazard ratio [sHR] 2.32, 95% confidence interval [CI]: 1.26-4.29, p=0.007). This association remained significant in non-frail patients (sHR 3.85, 95% CI: 2.13-6.95, p=0.001), but was not significant in patients with established frailty criteria (sHR 1.40, 95% CI: 0.72-2.75, p=0.325). The interaction invasive strategy-frailty was significant (p=0.032). CONCLUSIONS: An invasive strategy was independently associated with better outcomes in very elderly patients with NSTEACS. This association was different according to frailty status.

Global Geriatric Assessment and In-Hospital Bleeding Risk in Elderly Patients with Acute Coronary Syndromes: Insights from the LONGEVO-SCA Registry.

BACKGROUND: Bleeding risk scores have shown a limited predictive ability in elderly patients with acute coronary syndromes (ACS). No study explored the role of a comprehensive geriatric assessment to predict in-hospital bleeding in this clinical setting. METHODS: The prospective multicentre LONGEVO-SCA registry included 532 unselected patients with non-ST segment elevation ACS (NSTEACS) aged 80 years or older. Comorbidity (Charlson index), frailty (FRAIL scale), disability (Barthel index and Lawton-Brody index), cognitive status (Pfeiffer test) and nutritional risk (mini nutritional assessment-short form test) were assessed during hospitalization. CRUSADE score was prospectively calculated for each patient. In-hospital major bleeding was defined by the CRUSADE classification. The association between geriatric syndromes and in-hospital major bleeding was assessed by logistic regression method and the area under the receiver operating characteristic curves (AUC). RESULTS: Mean age was 84.3 years (SD 4.1), 61.7% male. Most patients had increased troponin levels (84%). Mean CRUSADE bleeding score was 41 (SD 13). A total of 416 patients (78%) underwent an invasive strategy, and major bleeding was observed in 37 cases (7%). The ability of the CRUSADE score for predicting major bleeding was modest (AUC 0.64). From all aging-related variables, only comorbidity (Charlson index) was independently associated with major bleeding (per point, odds ratio: 1.23, p = 0.021). The addition of comorbidity to CRUSADE score slightly improved the ability for predicting major bleeding (AUC: 0.68). CONCLUSION: Comorbidity was associated with major bleeding in very elderly patients with NSTEACS. The contribution of frailty, disability or nutritional risk for predicting in-hospital major bleeding was marginal.

An Easy Assessment of Frailty at Baseline Independently Predicts Prognosis in Very Elderly Patients With Acute Coronary Syndromes.

BACKGROUND: Information about the impact of frailty in patients with acute coronary syndromes (ACS) is scarce. No study has assessed the prognostic impact of frailty as measured by the FRAIL scale in very elderly patients with ACS. METHODS: The prospective multicenter LONGEVO-SCA registry included unselected patients with ACS aged 80 years or older. A comprehensive geriatric assessment was performed during hospitalization, including frailty assessment by the FRAIL scale. The primary endpoint was mortality at 6 months. RESULTS: A total of 532 patients were included. Mean age was 84.3 years, 61.7% male. Most patients had positive troponin levels (84%) and high GRACE risk score values (mean 165). A total of 205 patients were classified as prefrail (38.5%) and 145 as frail (27.3%). Frail and prefrail patients had a higher prevalence of comorbidities, lower left ventricle ejection fraction, and higher mean GRACE score value. A total of 63 patients (11.8%) were dead at 6 months. Both prefrailty and frailty were associated with higher 6-month mortality rates (P < .001). After adjusting for potential confounders, this association remained significant (hazard ratio [HR] 2.71; 95% confidence interval [CI] 1.09-6.73 for prefrailty and HR 2.99; 95% CI 1.20-7.44 for frailty, P = .024). The other independent predictors of mortality were age, Charlson Index, and GRACE risk score. CONCLUSIONS: The FRAIL scale is a simple tool that independently predicts mortality in unselected very elderly patients with ACS. The presence of prefrailty criteria also should be taken into account when performing risk stratification of these patients.