Cognitive impairment and treatment strategy for atrial fibrillation in older adults: The SAGE-AF study.

BACKGROUND: Cognitive impairment is strongly associated with atrial fibrillation (AF). Rate and rhythm control are the two treatment strategies for AF and the effect of treatment strategy on risk of cognitive decline and frailty is not well established. We sought to determine how treatment strategy affects geriatric-centered outcomes. METHODS: The Systematic Assessment of Geriatric Elements-AF (SAGE-AF) was a prospective, observational, cohort study. Older adults with AF were prospectively enrolled between 2016 and 2018 and followed longitudinally for 2 years. In a non-randomized fashion, participants were grouped by rate or rhythm control treatment strategy based on clinical treatment at enrollment. Baseline characteristics were compared. Longitudinal binary mixed models were used to compare treatment strategy with respect to change in cognitive function and frailty status. Cognitive function and frailty status were assessed with the Montreal Cognitive Assessment Battery and Fried frailty phenotype tools. RESULTS: 972 participants (mean age = 75, SD = 6.8; 49% female, 87% non-Hispanic white) completed baseline examination and 2-year follow-up. 408 (42%) were treated with rate control and 564 (58%) with rhythm control. The patient characteristics of the two groups were different at baseline. Participants in the rate control group were older, more likely to have persistent AF, prior stroke, be treated with warfarin and have baseline cognitive impairment. After adjusting for baseline differences, participants treated with rate control were 1.5 times more likely to be cognitively impaired over 2 years (adjusted OR: 1.47, 95% CI:1.12, 1.98) and had a greater decline in cognitive function (adjusted estimate: -0.59 (0.23), p < 0.01) in comparison to rhythm control. Frailty did not vary between the treatment strategies. CONCLUSIONS: Among those who had 2-year follow-up in non-randomized observational cohort, the decision to rate control AF in older adults was associated with increased odds of decline in cognitive function but not frailty.

Short and medium-term outcomes in individuals hospitalized with acute myocardial infarction and multiple chronic conditions: The Worcester heart attack study.

Background: Multiple chronic conditions (MCCs) are common in patients hospitalized with acute myocardial infarction (AMI). We examined the association of 12 MCCs with the risk of a 30-day hospital readmission and/or dying within one year among those discharged from the hospital after an AMI. We also examined the five most prevalent pairs of chronic conditions in this population and their association with the principal study endpoints. Methods: The study population consisted of 3,294 adults hospitalized with a confirmed AMI at the three major medical centers in central Massachusetts on an approximate biennial basis between 2005 and 2015. Patients were categorized as ≤1, 2-3, and ≥4 chronic conditions. Results: The median age of the study population was 67.9 years, 41.6% were women, and 15% had ≤1, 32% had 2-3, and 53% had ≥4 chronic conditions. Patients with ≥4 conditions tended to be older, had a longer hospital stay, and received fewer cardiac interventional procedures. There was an increased risk for being rehospitalized during the subsequent 30 days according to the presence of MCCs, with the highest risk for those with ≥4 conditions. There was an increased, but attenuated, risk for dying during the next year according to the presence of MCCs. Individuals with diabetes/hypertension and those with heart failure/chronic kidney disease were at particularly high risk for developing the principal study outcomes. Conclusion: Development of guidelines that include complex patients, particularly those with MCCs and those at high risk for adverse short/medium term outcomes, remain needed to inform best treatment practices.

Characteristics associated with poor atrial fibrillation-related quality of life in adults with atrial fibrillation.

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.

Differential effect of anticoagulation according to cognitive function and frailty in older patients with atrial fibrillation.

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.

Medication cost-reducing behaviors in older adults with atrial fibrillation: The SAGE-AF study.

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.

Cognitive impairment, age, quality of life, and treatment strategy for atrial fibrillation in older adults: The SAGE-AF study.

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.

Online health information seeking, low atrial fibrillation-related quality of life, and high perceived efficacy in patient-physician interactions in older adults with atrial fibrillation.

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.

Association between risk of obstructive sleep apnea and cognitive performance, frailty, and quality of life among older adults with atrial fibrillation.

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.

Factors Associated with Moderate Physical Activity Among Older Adults with Atrial Fibrillation.

OBJECTIVE: Engaging patients with atrial fibrillation (AF) in moderate-intensity physical activity has been encouraged by published guidelines. We examined factors associated with engagement in moderate physical activity among older adults with AF. METHODS: This was a retrospective study involving ninety patients with episodes of Afib with RVR duData are from the SAGE (Systematic Assessment of Geriatric Elements)-AF study. Older adults (≥ 65 years) with AF and a CHA2DS2-VASc ≥ 2 were recruited from several clinics in Massachusetts and Georgia between 2015 and 2018. The Minnesota Leisure Time Physical Activity questionnaire was used to assess whether participants engaged in moderate-intensity physical activity (i.e. at least 150 minutes of moderate exercise). Logistic regression was utilized to examine the sociodemographic and clinical characteristics and geriatric elements associated with engaging in moderate-intensity physical activity. RESULTS: Participants were on average 76 years old and 48% were women. Approximately one-half (52%) of study participants engaged in moderate-intensity physical activity. Morbid obesity (adjusted OR [aOR]=0.41, 90%CI=0.23-0.73), medical history of renal disease (aOR= aOR=0.68,90%CI= 0.48-0.96), slow gait speed (aOR=0.44, 90%CI=0.32-0.60), cognitive impairment (aOR=0.74, 90%CI=0.56-0.97), and social isolation (aOR=0.58, 90%CI= 0.40-0.84) were independently associated with a lower likelihood, while higher AF related quality of life score (aOR=1.64, 90%CI=1.25-2.16) a greater likelihood, of meeting recommended levels of moderate physical activity. CONCLUSIONS: Nearly one-half of older adults with NVAF did not engage in moderate-intensity exercise. Clinicians should identify older patients with NVAF who are less likely to engage in physical activity and develop tailored interventions to promote regular physical activity.

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.

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.

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.

Differences in Perceived and Predicted Bleeding Risk in Older Adults With Atrial Fibrillation: The SAGE-AF Study.

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.

Temporal Trends and Patient Characteristics Associated with 30-Day Hospital Readmission Rates after a First Acute Myocardial Infarction.

BACKGROUND: Limited data exist about relatively recent trends in the magnitude and characteristics of patients who are re-hospitalized after hospital admission for an acute myocardial infarction. This study examined trends in the frequency and sociodemographic and clinical characteristics of patients readmitted to the hospital within 30 days after an initial acute myocardial infarction. METHODS: We reviewed the medical records of 3116 individuals who were hospitalized for a validated first acute myocardial infarction in 6 study periods between 2003 and 2015 at the 3 major medical centers in central Massachusetts. RESULTS: The median age of our population was 67 years, and 42% were women. The risk of being readmitted to the hospital within 30 days after an initial acute myocardial infarction increased slightly during the most recent study years after controlling for potentially confounding factors. Overall, older adults and patients with previously diagnosed atrial fibrillation, heart failure, diabetes, chronic kidney disease, stroke, and peripheral vascular disease were at higher risk for being readmitted to the hospital than respective comparison groups. For those hospitalized in the most recent study years of 2011/2015, a higher risk of rehospitalization was associated with a previous diagnosis of chronic kidney disease, peripheral vascular disease, the presence of 3 or more chronic conditions, and having developed atrial fibrillation or heart failure during the patient's hospitalization for a first acute myocardial infarction. CONCLUSIONS: We identified several groups at higher risk for hospital readmission in whom enhanced surveillance efforts as well as tailored educational and treatment approaches remain needed.

Multimorbidity, physical frailty, and self-rated health in older patients with atrial fibrillation.

BACKGROUND: Holistic care models emphasize management of comorbid conditions to improve patient-reported outcomes in treatment of atrial fibrillation (AF). We investigated relations between multimorbidity, physical frailty, and self-rated health (SRH) among older adults with AF. METHODS: Patients (n = 1235) with AF aged 65 years and older were recruited from five medical centers in Massachusetts and Georgia between 2015 and 2018. Ten previously diagnosed cardiometabolic and 8 non-cardiometabolic conditions were assessed from medical records. Physical Frailty was assessed with the Cardiovascular Health Study frailty scale. SRH was categorized as either "excellent/very good", "good", and "fair/poor". Separate multivariable ordinal logistic models were used to examine the associations between multimorbidity and SRH, physical frailty and SRH, and multimorbidity and physical frailty. RESULTS: Overall, 16% of participants rated their health as fair/poor and 14% were frail. Hypertension (90%), dyslipidemia (80%), and heart failure (37%) were the most prevalent cardiometabolic conditions. Arthritis (51%), anemia (31%), and cancer (30%), the most common non-cardiometabolic diseases. After multivariable adjustment, patients with higher multimorbidity were more likely to report poorer health status (Odds Ratio (OR): 2.15 [95% CI: 1.53-3.03], ≥ 8 vs 1-4; OR: 1.37 [95% CI: 1.02-1.83], 5-7 vs 1-4), as did those with more prevalent cardiometabolic and non-cardiometabolic conditions. Patients who were pre-frail (OR: 1.73 [95% CI: 1.30-2.30]) or frail (OR: 6.81 [95% CI: 4.34-10.68]) reported poorer health status. Higher multimorbidity was associated with worse frailty status. CONCLUSIONS: Multimorbidity and physical frailty were common and related to SRH. Our findings suggest that holistic management approaches may influence SRH among older patients with AF.

Self-reported risk of stroke and factors associated with underestimation of stroke risk among older adults with atrial fibrillation: the SAGE-AF study.

BACKGROUND: Though engaging patients with atrial fibrillation (AF) in understanding their stroke risk is encouraged by guidelines, little is known regarding AF patients' perceived stroke risk or its relationship with oral anticoagulation (OAC) use. We aim to identify factors associated with underestimation of stroke risk among older patients with AF and relate this to OAC use. METHODS: Data are from the ongoing SAGE (Systematic Assessment of Geriatric Elements)-AF study, which included older patients (> 65 years) with non-valvular AF and a CHA2DS2-VASc score of ≥ 2. Participants reported their perceived risk of having a stroke without OAC. We compared the perceived risk to CHA2DS2-VASc predicted stroke risk and classified participants as "over" or "under" estimators, and identified factors associated with underestimation of risk using multiple logistic regression. RESULTS: The average CHA2DS2-VASc score of 915 participants (average age: 75 years, 47% female, 86% white) was 4.3 ± 1.6, 43% of participants had discordant predicted and self-reported stroke risks. Among the 376 participants at highest risk (CHA2DS2-VASc score ≥ 5), 46% of participants underestimated their risk. Older participants (≥ 85 years) were more likely and OAC treated patients less likely to underestimate their risk of developing a future stroke than respective comparison groups. CONCLUSIONS: A significant proportion of study participants misperceived their stroke risk, mostly by overestimating. Almost half of participants at high risk of stroke underestimated their risk, with older patients more likely to do so. Patients on OAC were less likely to underestimate their risk, suggesting that successful efforts to educate patients about their stroke risk may influence treatment choices.

Frailty, Cognitive Impairment, and Anticoagulation Among Older Adults with Nonvalvular Atrial Fibrillation.

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.

Impact of comorbid conditions on disease-specific quality of life in older men and women with atrial fibrillation.

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.

Psychosocial and cognitive multimorbidity and health-related quality of life and symptom burden in older adults with atrial fibrillation: The systematic assessment of geriatric elements in atrial fibrillation (SAGE-AF) cohort study.

BACKGROUND: Depression, anxiety, and cognitive impairments occur in up to 40 % of adults with AF and are associated with poorer health-related quality of life (HRQoL) and higher symptom burden. However, it is unknown how often these impairments co-occur, or multimorbidity, and how multimorbidity effects HRQoL and symptom burden. METHODS: Patients with AF age ≥65 years with a CHA2DS2VASC risk score ≥ 2 and eligible for oral anticoagulation therapy were recruited from five clinics in a prospective cohort study. Participants completed validated measures of depression (PHQ9) and anxiety (GAD7), cognitive impairment (MoCA), and HRQOL and AF symptom burden (AFEQT). Multinomial logistic regression was used. RESULTS: Participants (N = 1244, 49 % female) were on average 76 ± 7 years; 86 % were non-Hispanic white. Approximately 35 % of participants had 1 impairment, 17 % had 2 impairments and 8% had 3 impairments; 39 % had none of the 3 impairments examined. Compared to participants with no impairments, patients with 1, 2 and 3 impairments had higher odds of poor HRQoL (adjusted OR [AOR] = 1.77, 95 % CI 1.21, 2.60; AOR = 6.64, 95 % CI 4.43, 9.96; and AOR = 7.50, 95 % CI 4.40, 12.77, respectively) and those with 2 and 3 impairments had higher odds of high symptom burden (AOR = 3.69 95 % CI 2.22, 6.13; and AOR = 5.41 95 % CI 2.85, 10.26). CONCLUSIONS: Psychosocial/cognitive multimorbidity is common among older adults with AF and is associated with poor HRQoL and high symptom burden. Clinicians might consider incorporating psychosocial and cognitive screens into routine care as this may identify a high-risk population.

Impact of a depression counseling intervention on student pharmacists' confidence and comfortability: A pilot study.

INTRODUCTION: The objective of this study was to assess the impact of a mental health educational intervention on pharmacy students' confidence and comfortability when engaging in depression counseling. METHODS: Third-year pharmacy students completed two 15-item rating scales addressing confidence and comfortability about depression. The intervention was 2.5 hours long and included a depression overview, consumer educator presentation, motivational interviewing, and case studies. Surveys were administered at baseline, immediately after the intervention, and three months post intervention. Data were analyzed using paired t-tests and repeated measures analyses. RESULTS: Of the 23 students who participated in the intervention, 12 (52.2%) completed the three-month follow-up. Confidence increased significantly (p < 0.05) from 3.5 ± 0.5 to 4.1 ± 0.4 immediately post intervention and was sustained at three months post (3.9 ± 0.5). Similarly, comfortability increased significantly (p < 0.05) from 3.6 ± 0.4 to 4.1 ± 0.5 immediately post and was sustained at three months post (4.1 ± 0.6). Cronbach's alphas ranged from 0.90 to 0.96. CONCLUSION: Pharmacy students' depression counseling confidence and comfortability improved and was sustained after a 2.5-hour intervention with motivational interviewing, consumer education, and case studies.

Willingness to Seek Help for Depression in Young African American Adults: Study Protocol.

BACKGROUND: In the United States, among those living with mental illness, 81% of African American (AA) young adults do not seek treatment compared with 66% of their white counterparts. Although the literature has identified unique culturally related factors that impact help seeking among AAs, limited information exists regarding the development and evaluation of interventions that incorporate these unique factors. OBJECTIVE: This study aims to describe a study protocol designed to develop a culturally relevant, theory-based, psychoeducational intervention for AA young adults; to determine if exposure to the intervention impacts AA young adults' willingness to seek help; and to determine whether cultural factors and stigma add to the prediction of willingness to seek help. METHODS: The Theory of Planned Behavior (TPB) and Barrera and Castro's framework for cultural adaptation of interventions were used as guiding frameworks. In stage 1 (information gathering), a literature review and three focus groups were conducted to identify salient cultural beliefs. Using stage 1 results, the intervention was designed in stage 2 (preliminary adaptation design), and in stage 3 (preliminary adaptation tests), the intervention was tested using pretest, posttest, and 3-month follow-up surveys. An experimental, mixed methods, prospective one-group intervention design was employed, and the primary outcomes were participants' willingness and intention to seek help for depression and actual help-seeking behavior. RESULTS: This study was funded in May 2016 and approved by the University of Texas at Austin institutional review board. Data were collected from November 2016 to March 2016. Of the 103 students who signed up to participate in the study, 70 (67.9%) completed the pre- and posttest surveys. The findings are expected to be submitted for publication in 2020. CONCLUSIONS: The findings from this research are expected to improve clinical practice by providing empirical evidence as to whether a culturally relevant psychoeducational intervention is useful for improving help seeking among young AAs. It will also inform future research and intervention development involving the TPB and willingness to seek help by identifying the important factors related to willingness to seek help. Advancing this field of research may facilitate improvements in help-seeking behavior among AA young people and reduce the associated mental health disparities that apparently manifest early on. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/16267.