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Abstract
Objective To assess the prevalence of major geriatric syndromes (MGSs)―frailty, cognitive impairment, severe dependence and depression―and their influence on outcomes in unselected patients with acute cardiac diseases.
Design Observational prospective study with 12-month clinical and functional follow-up.
Setting Clinical cardiology unit of a university hospital in Madrid, Spain.
Patients Consecutive patients ≥75 years old urgently admitted to the cardiology unit.
Intervention Systematic comprehensive geriatric assessment.
Main outcome measures 12-month rates of mortality, readmission, functional decline and need for new social help.
Results Among the 211 patients studied, 127 (60.2%) presented at least one MGS on admission: 86 frailty (40.8%), 67 cognitive impairment (31.8%), 31 severe dependency (14.7%) and 9 depression (4.3%). Patients with MGSs were slightly older (82±5 vs 81±4 years, p=0.02) but did not show greater disease severity or comorbidity. The presence of MGSs was associated with a higher incidence of functional decline during hospitalisation (35.7% vs 8.6%, p=0.002) and higher 12-month age-, comorbidity- and diagnosis-adjusted risks of readmission (OR, 2.1.92; 95% CI 0.98 to 3.7), functional decline (OR, 2.86; 95% CI 1.41 to 5.79) and need for new social help (OR, 3.10; 95% CI 1.45 to 6.60). MGSs were also associated with a higher 12-month mortality rate, which was only obvious in patients hospitalised for heart failure but not for other reasons.
Conclusions A majority of older patients hospitalised for acute cardiac conditions in a cardiology department show at least one MGS on admission. MGSs are associated with poorer inhospital and postdischarge functional and clinical outcomes, particularly in patients with heart failure.
- Geriatric syndromes
- cardiovascular disease
- risk assessment
- frailty
- depression
- functional impairment
- heart failure
- depression
- old age
- risk stratification
- coronary artery disease (CAD)
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- Geriatric syndromes
- cardiovascular disease
- risk assessment
- frailty
- depression
- functional impairment
- heart failure
- depression
- old age
- risk stratification
- coronary artery disease (CAD)
The accelerated ageing of the population and the lower threshold to provide advanced specialised care to most patients regardless of their age are leading to a quick increase in the proportion of very old patients hospitalised in medical or surgical specialty units. As cardiovascular diseases are the principal cause of death and hospitalisation in older individuals, cardiology units are particularly affected by this trend. The age-related changes in presentation and outcomes of acute cardiac diseases are well known,1–4 and the influence of some geriatric conditions on the evolution of specific cardiac diseases have been described,5–11 but routine clinical evaluation in cardiology does not include the assessment of specific geriatric conditions. Thus, there is a shortage in the knowledge of the prevalence of geriatric syndromes in patients with cardiac disease, of their influence on outcomes and particularly on how they should be integrated on clinical decision making. In addition, the effectiveness of a comprehensive geriatric assessment in older patients admitted to cardiology units needs to be evaluated. We aimed to assess the prevalence of geriatric syndromes in a cohort of unselected older patients admitted to a cardiology unit for an acute cardiac disease and assess their influence on short- and mid-term clinical and functional outcomes.
Methods
A prospective, observational study was conducted on a series of older patients consecutively admitted to the cardiology department of a large university hospital for an acute cardiac condition. Inclusion criteria were age ≥75 years and direct urgent admission to the cardiology department (coronary care unit or cardiology ward) of Hospital General Universitario Gregorio Marañón, a 1800-bed hospital in Madrid, Spain. Exclusion criteria were terminal status in the first 24 h after admission, programmed admission and patient refusal to participate in the study after informed consent. Each patient was contacted and requested to provide an informed consent to participate in the study. Once accepted, a specialist physician in geriatric medicine recorded all relevant information on the patient's baseline medical, functional, mental and socio-demographic status as well as on acute clinical condition through a personal interview, a complete geriatric evaluation and a review of the medical record performed during hospitalisation. Comorbidity was measured with the Charlson index12, and disease severity, with the Acute Physiology and Chronic Health Evaluation (APACHE) II score.13
Geriatric syndromes
We selected from the literature a group of geriatric syndromes that had shown an influence on prognosis or dependence generation specifically in patients with cardiac diseases. Thus, we defined major geriatric syndromes (MGSs) for this study as the presence of one of the following: severe functional dependence, cognitive impairment, depression or frailty on admission. Baseline functional status was evaluated as the independence to perform six basic activities of daily living (ADLs)—bathing, dressing, transferring, toileting, continence and feeding—2 weeks before their admission. These are obtained by interviewing the patient, or a proxy or care giver if needed. Each item is scored as ‘1’ for complete independence and ‘0’ when personal assistance was needed. Severe dependence was considered when the total score was ≤3, that is, if the patient was dependent to carry out three or more ADLs. Cognitive impairment was evaluated using the validated Spanish translation of Mini-Mental State Examination,14 a test that scores from 0 (worst) to 35 (normal). A diagnosis of cognitive impairment was established if the score was <22 (cut-off adjusted to the patient education level). The presence of depression was evaluated by the geriatric depression scale of Yessavage,15 a 15-item scale with 15 points as the maximum score and a score >9 as an indication of the presence of established depression. The presence of frailty was evaluated following the criteria of Fried,16 which assess five fundamental aspects: the presence of unintentional weight loss, self-reported exhaustion, muscle weakness (grip strength), slow walking speed and low physical activity. A patient was considered frail when three or more of these criteria were present.
Additionally, the presence of other geriatric conditions or disabilities such as mobility impairment (great difficulty or inability to go up a flight of stairs or walk 400 m consecutively without the help of another person),17 recurrent falls, urinary incontinence or visual and hearing impairment was analysed. Coexisting acute diseases were defined as concomitant acute or chronic exacerbated non-cardiac diseases present at any moment during hospitalisation.
Outcomes
Clinical and functional outcomes, including mortality, readmission, functional decline and need for new social help for ADL performance, were evaluated. All the patients underwent a telephone interview 12 months after discharge. During the interview, the patients (or a care giver when needed) were asked about their vital status (mortality), the occurrence of readmissions, the ability to perform independently the six basic ADLs previously described and the need for new personal support to help perform the ADLs. Information on mortality and readmission was checked and completed by medical records review. All-cause mortality was measured. Readmission was defined as any unplanned hospitalisation after discharge during follow-up. Functional decline was defined as the loss of at least one point in the ADL total score with respect to preadmission status. Need for new social help was defined as the need for institutionalisation or the increase in personal support for the development of ADLs as compared with the situation before admission.
Statistical analysis
Results are presented as means±SDs for continuous variables with normal distribution and counts and percentages for discrete variables. Differences between groups were compared with χ2 tests or Fisher exact tests for discrete variables, and analysis of variance for continuous variables. Logistic regression analyses were used to examine the independent association between the presence of major geriatric syndromes and outcomes (mortality, readmission, functional decline and new social help) at 12 months, adjusting for age, comorbidity and main diagnosis on admission. The adjusted risks associated with each individual outcome were calculated. Survival was evaluated with Kaplan–Meier curves and compared with log-rank tests. Differences in survival between groups adjusted for age, comorbidity and main diagnosis were analysed by Cox regression analysis.
Results
Between 1 February and 31 March 2008, 444 patients were admitted to the cardiology department from the emergency room. Of those, 224 (51.4%) were ≥75 years old. Four patients in terminal situation were excluded, and nine refused participation in the study, so the final study group consisted of 211 patients.
Mean age was 81.6±5 years (range 75–95 years). The baseline characteristics of the group are shown in table 1. The main causes of admission were acute or decompensated heart failure, acute coronary syndromes and rhythm disturbances. Comorbidity and disease severity indices were high (mean Charlson index 3.06±2; mean APACHE II index 10±3). A left ventricular ejection fraction <0.50 was found in 84 patients (40%). Mean length of stay during hospitalisation was 7±4.6 days.
Baseline characteristics and admission diagnosis of the study group according to the presence of major geriatric syndromes (n=211 patients)
The prevalence of any MGS was 60.2% (n=127 patients). Table 2 shows the prevalence of each geriatric syndrome. During hospital stay, at least one coexisting acute disease was identified in 111 patients (52.6%), mainly acute renal failure (n=76, 37%), exacerbated chronic obstructive pulmonary disease (n=29, 15%), pneumonia (n=7, 3%) and other infections (n=22, 11%). Mortality rates were 3.3% in hospital (n=7) and 23.2% at 1 year (n=47). Patients with MGS on admission were older but not sicker than those without MGS according to disease severity, comorbidity or coexisting acute diseases (table 1).
Prevalence of geriatric syndromes and conditions in 211 unselected older patients admitted for acute cardiac disease to a cardiology unit
Clinical follow-up was completed in 209 patients (99.1%), and functional status could be assessed in 141 patients at 12 months (87.7% of those surviving). Patients presenting with at least one MGS on admission showed no significant difference in hospital mortality but higher 12-month mortality and readmission rates (table 3, figure 1A) than patients without MGS. These patients also showed a higher rate of functional decline during hospitalisation and follow-up (table 3). Moreover, after adjusting for age, comorbidity and cause of admission, the presence of at least one MGS on admission was associated with a higher risk of readmission, functional decline and need for new social help at 12 months (table 4, figure 2). Patients with MGSs did not show a statistically significant increase in the 12-month adjusted mortality risk in the overall population (figure 2), but MGSs were associated with a higher mortality rate in patients hospitalised for heart failure and not for other reasons (figure 1B).
Differences in hospital and 12-month outcomes between patients with and without major geriatric syndromes
Survival curves according to the presence of major geriatric syndromes on admission in all patients (A) and split according to admission diagnosis, heart failure vs others (B).
Independent predictors of the studied individual 12-month outcomes
Influence of major geriatric syndromes on clinical and functional outcomes at 12 months in older patients hospitalised for acute cardiac conditions, adjusted for age, comorbidity and cause of admission (heart failure vs others).
Discussion
Our study shows that a majority of older patients admitted to a cardiology unit for an acute cardiac reason present at least one MGS on admission, which is associated with poorer clinical and functional outcomes in hospital and during follow-up, and that this is especially true for patients hospitalised for heart failure.
Geriatric syndromes are multifactorial health conditions, highly prevalent in older adults, that occur when the accumulated effects of impairments in multiple systems render (an older) person vulnerable to situational challenges, constitute a common way of presenting multiple underlying diseases and have a substantial impact on quality of life, disability and prognosis.18 This broad definition includes a large and heterogeneous variety of conditions. For practical reasons, we have used the concept of MGS, including only conditions with proven prognostic importance in terms of mortality or generation of dependence specifically in patients with cardiac diseases.19–25
To our knowledge, this is the first study to prospectively assess a large set of geriatric syndromes and conditions in a series of unselected patients urgently hospitalised for acute cardiac conditions and evaluate their influence on clinical prognosis as well as functional and social recovery. Previous studies in patients with cardiac disease had focused on specific individual geriatric syndromes or on patients with individual cardiac conditions, such as heart failure, coronary artery disease or coronary artery bypass grafting.5 6 8 10 26–29
The identification of MGS may help address the difference between chronological and biological age, an intangible concept frequently used in cardiology and cardiac surgery for risk evaluation and clinical decision making for very old patients.30 The use of a comprehensive geriatric assessment31 has demonstrated benefits on clinical and functional outcomes in different clinical settings32–35 when targeted to appropriate patients and when followed by specific recommendations and a plan of action. However, the specific benefit of this intervention during hospitalisation in patients with acute cardiac disease is unknown. Our results suggest that the assessment of MGS during hospitalisation helps identify patients at high risk for early functional decline and mid-term unfavourable clinical and functional outcomes. Thus, a comprehensive geriatric assessment should be incorporated to routine clinical practice for older patients with acute cardiac disease. As cardiologists are not trained in geriatric assessment and this information may facilitate improving individual patient-centred decisions in older patients with cardiac disease, a multidisciplinary approach will be needed to provide the best care to the oldest patients with acute heart disease. Therefore, new models of care in cardiology units for older patients should be evaluated.
A key issue is whether geriatric syndromes and their consequences can be prevented and/or treated. The underlying causes of geriatric syndromes are not always clear as multiple risk factors and systems can be involved. However, different clinical programs have demonstrated to be effective in preventing functional decline in high-risk patients hospitalised in other settings.36–38 It is possible that postdischarge interventions based on physical therapy and a multidisciplinary supervision of self-care and control of comorbid diseases could improve the prognosis of patients with cardiac diseases and geriatric syndromes, particularly among those with heart failure.
Our study has strengths and limitations. This is the first prospective study with a careful systematic geriatric specialist evaluation in a series of unselected consecutive patients hospitalised for acute cardiac conditions with mid-term functional and clinical follow-up. However, a number of limitations are present. First, although our definition of MGS is restrictive and based on the entities that have demonstrated a clear impact on functional and/or clinical prognosis, it has not been previously validated. Second, our study was not powered to evaluate the isolated effect of each individual geriatric syndrome on prognosis, and these may differ among them. Third, the patient's clinical situation in an acute hospital setting (ie, the disease itself, the use of hypnotics or the presence of intravenous lines or urinary catheters) might have interfered with the assessment of some capacities, such as mental evaluation and gait speed. Finally, not all patients could have a complete evaluation in hospital (frailty was assessed in the last 155 patients) or during follow-up. However, the early failure to assess frailty could have only led to underestimation of its prevalence and MGS as a whole, while the consecutive evaluation of all other patients should have prevented from bias in its influence on outcomes. Losses to follow-up were equally distributed between the groups with and without MGS and so should not bias our results, which, in addition, are concordant with previous findings in other clinical settings.
In conclusion, a very high proportion of older patients hospitalised for acute cardiac conditions present concomitant MGSs that slow their recovery, impair their prognosis and frequently require specialised non-cardiac care. A multidisciplinary approach should be helpful to provide an integral patient-centred care for older patients with acute cardiac diseases, particularly those with heart failure.
References
Footnotes
Competing interests None.
Patient consent Obtained.
Ethics approval This study was conducted with the approval of the Ethics Committee of Hospital General Universitario Gregorio Marañón.
Provenance and peer review Not commissioned; externally peer reviewed.