Polyscore of autonomic parameters for risk stratification of the elderly general population: the Polyscore study.

AIMS: Present society is constantly ageing and elderly frequently suffer from conditions that are difficult and/or costly to treat if detected late. Effective screening of the elderly is therefore needed so that those requiring detailed clinical work-up are identified early. We present a prospective validation of a screening strategy based on a Polyscore of seven predominantly autonomic, non-invasive risk markers. METHODS AND RESULTS: Within a population-based survey in Germany (INVADE study), participants aged ≥60 years were enrolled between August 2013 and February 2015. Seven prospectively defined Polyscore components were obtained during 30-min continuous recordings of electrocardiogram, blood pressure, and respiration. Out of 1956 subjects, 168 were excluded due to atrial fibrillation, implanted pacemaker, or unsuitable recordings. All-cause mortality over a median 4-year follow-up was prospectively defined as the primary endpoint. The Polyscore divided the investigated population (n = 1788, median age: 72 years, females: 58%) into three predefined groups with low (n = 1405, 78.6%), intermediate (n = 326, 18.2%), and high risk (n = 57, 3.2%). During the follow-up, 82 (4.6%) participants died. Mortality in the Polyscore-defined risk groups was 3.4%, 7.4%, and 17.5%, respectively (P < 0.0001). The Polyscore-based mortality prediction was independent of Framingham score, diabetes, chronic kidney disease, and major stroke and/or myocardial infarction history. It was particularly effective in those aged <75 years (n = 1145). CONCLUSION: The Polyscore-based mortality risk assessment from short-term non-invasive recordings is effective in the elderly general population, especially those aged 60-74 years. Implementation of a comprehensive Polyscore screening of this age group is proposed to advance preventive medical care.

[Prevention of stroke and dementia in general practice: evaluation of the project INVADE]. / Prävention von Schlaganfall und Demenz in der Hausarztpraxis: Evaluation des Projektes INVADE.

BACKGROUND: Stroke and dementia have several modifiable risk factors in common. In the primary care prevention project INVADE (INtervention project on VAscular brain diseases and Dementia in the district of Ebersberg), these vascular risk factors were recorded systematically and treated according to evidence-based guidelines. METHODS: All insurants of the AOK Bayern who were ≥ 50 years of age and lived in the Upper Bavarian district of Ebersberg received the offer to participate in INVADE, about one-third enrolled in the program. Examinations by the family doctor, self-reports of the participants, laboratory analyses, and a duplex sonography of the extracranial neck vessels were used to create individual risk profiles, from which the intervention measures were derived. GPs documented the treatment and health status of the participants at quarterly intervals. The entire examination program was repeated every two years. The success of the intervention was determined in comparison with the district of Dachau, where the insurants received the primary care treatment as usual. Administrative data of the health and long-term care fund for the period from 2013 to 2016 were used as clinical endpoints. Primary endpoints included mortality and onset of long-term care, secondary endpoints were inpatient treatments due to cerebrovascular disease. RESULTS: The comparison between the district of Ebersberg (N = 10.663) and the district of Dachau (N = 13.225) was in favor of the prevention program for both the primary clinical endpoints and the combined secondary endpoint. Mortality risk (HR = 0.90; 95 % confidence interval: 0.84-0.97), long-term care risk (HR = 0.88; 0.81-0.96), and the likelihood of inpatient treatment for cerebrovascular disease (OR = 0.87; 0.77-0.97) were significantly reduced. CONCLUSIONS: The results support the assumption that the incidence of cerebrovascular disease and dementia can be reduced by a systematic general-practice based identification and treatment of vascular risk factors and can thus increase life expectancy and disability-free life time. REGISTRATION: clinicaltrials.gov, NCT1107548, registration date: 21.04.2010, drks.de, DRKS00011348, registration date: 29.12.2016.

Smoking increases the risk of delirium for older inpatients: a prospective population-based study.

OBJECTIVES: To investigate the association between smoking in the older population and the risk of inpatient delirium, which is common and has adverse consequences. METHOD: Participants (N=3754) were insurants aged ≥55years of the largest German statutory health insurance company, who enrolled in a 6-year prospective population-based study. Baseline smoking, adjusted for age, sex, depressive symptoms, cognitive impairment and alcohol consumption, was analyzed as risk factor of inpatient delirium. Results are presented as hazard ratios (HRs) and 95% confidence intervals (95% CIs). RESULTS: Three-hundred seventy-three (10.0%) participants were smokers at baseline, 865 (23.0%) were quitters and 2516 (67.0%) were lifelong abstainers. Mean pack-years of smokers and quitters were 23.8 (S.D.=22.4). Sixty-one (1.6%) received a diagnosis of inpatient delirium. Smokers had an increased risk of delirium compared to abstainers in the fully adjusted model (HR=2.87, 95% CI 1.24-6.66). Quitters and abstainers did not differ (HR=0.79, 95% CI 0.37-1.72). Comparing smokers and quitters, current smoking status (HR=3.22, 95% CI 1.20-8.62) but not pack-years [residual χ(2)(1)=0.25, P=.874] were associated with inpatient delirium. CONCLUSION: Only current smoking but not being a quitter and the lifetime amount smoked were associated with inpatient delirium, indicating that acute nicotine withdrawal may represent a relevant pathogenic mechanism.

Reduction of Long-Term Care Dependence After an 8-Year Primary Care Prevention Program for Stroke and Dementia: The INVADE Trial.

BACKGROUND: Stroke and dementia are the major causes for long-term care (LTC) dependence in old age. This intervention trial compared a multidomain prevention program for stroke and dementia with usual medical care in reducing the need for LTC. METHODS AND RESULTS: The Intervention Project on Cerebrovascular Disease and Dementia in the District of Ebersberg (INVADE) was a general practice-based 8-year trial in 2 defined catchment areas in Upper Bavaria, Germany. All 11 317 insurants of a statutory health insurance plan who were ≥55 years of age and lived in the intervention district were offered the opportunity to participate in a prevention program; 3908 enrolled. The 13 301 insurants in the reference district received usual medical care. The intervention consisted of the systematic identification and evidence-based treatment of vascular risk factors. The primary clinical end point was incidence of LTC dependence according to external assessment by a special medical service in the framework of the statutory German LTC insurance. Age- and sex-specific incidence rates from the reference district were used to calculate the expected number of cases of LTC dependence under usual medical care. The expected number was compared with the observed number of cases in the intervention district. Analysis was by intention to treat. During the 5 years after completion of the recruitment period, significantly fewer incident cases of LTC dependence arose in the intervention district than expected (χ(2)=13.25; P<0.001). In women, the incidence was reduced by 10% (P<0.01). In men, the incidence was reduced by 9.6% (P<0.05). CONCLUSIONS: Our results support the feasibility and effectiveness of a primary care prevention program for stroke and dementia to reduce the risk of developing LTC dependence. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01107548. (J Am Heart Assoc. 2012;1:e000786 doi: 10.1161/JAHA.112.000786.).