Risk Stratification Of Older Patients Research Articles

Impact of peri-operative frailty and operative stress on post-discharge mortality, readmission and days at home in Medicare beneficiaries.

Understanding how patients' frailty and the physiological stress of surgical procedures affect postoperative outcomes may inform risk stratification of older patients undergoing surgery. The objective of the study was to examine the association of peri-operative frailty with mortality, 30-day readmission and days at home after non-cardiac surgical procedures of different physiological stress. This retrospective study used Medicare claims data from a 7.125% random sample of Medicare fee-for-service beneficiaries from 2015 to 2019 who were aged ≥ 65 years and underwent non-cardiac surgical procedure listed in the Operative Stress Score categories. The exposure of the study was claims-based frailty index (robust, < 0.15; pre-frail, 0.15 to < 0.25; mildly frail, 0.25 to < 0.35; and moderate-to-severely frail, ≥ 0.35) with Operative Stress Score categories being 1, very low stress to 5, very high stress. The primary outcome was all-cause mortality at 30 days and 365 days after the surgical procedure. In total, 1,019,938 patients (mean (SD) age of 76.1 (7.3) years; 52.3% female; 16.8% frail) were included. The cumulative incidence of mortality generally increased with Operative Stress Score category, ranging from 5.0% (Operative Stress Score 2) to 24.9% (Operative Stress Score 4) at 365 days. Within each category, increasing frailty was associated with mortality at 30 days (hazard ratio comparing moderate-to-severe frailty vs. robust ranged from 1.59-3.91) and at 365 days (hazard ratio 1.30-4.04). The variation in postoperative outcomes by patients' frailty level was much greater than the variation by the operative stress category. These results emphasise routine frailty screening before major and minor non-cardiac procedures and the need for greater clinician awareness of postoperative outcomes beyond 30 days in shared decision-making with older adults with frailty.

Identifying Age-Specific Risk Factors for Poor Outcomes After Trauma With Machine Learning

IntroductionRisk stratification for poor outcomes is not currently age-specific. Risk stratification of older patients based on observational cohorts primarily composed of young patients may result in suboptimal clinical care and inaccurate quality benchmarking. We assessed two hypotheses. First, we hypothesized that risk factors for poor outcomes after trauma are age-dependent and, second, that the relative importance of various risk factors are also age-dependent. MethodsA cohort study of severely injured adult trauma patients admitted to the intensive care unit 2014-2018 was performed using trauma registry data. Random forest algorithms predicting poor outcomes (death or complication) were built and validated using three cohorts: (1) patients of all ages, (2) younger patients, and (3) older patients. Older patients were defined as aged 55 y or more to maintain consistency with prior trauma literature. Complications assessed included acute renal failure, acute respiratory distress syndrome, cardiac arrest, unplanned intubation, unplanned intensive care unit admission, and unplanned return to the operating room, as defined by the trauma quality improvement program. Mean decrease in model accuracy (MDA), if each variable was removed and scaled to a Z-score, was calculated. MDA change ≥4 standard deviations between age cohorts was considered significant. ResultsOf 5489 patients, 25% were older. Poor outcomes occurred in 12% of younger and 33% of older patients. Head injury was the most important predictor of poor outcome in all cohorts. In the full cohort, age was the most important predictor of poor outcomes after head injury. Within age cohorts, the most important predictors of poor outcomes, after head injury, were surgery requirement in younger patients and arrival Glasgow Coma Scale in older patients. Compared to younger patients, head injury and arrival Glasgow Coma Scale had the greatest increase in importance for older patients, while systolic blood pressure had the greatest decrease in importance. ConclusionsSupervised machine learning identified differences in risk factors and their relative associations with poor outcomes based on age. Age-specific models may improve hospital benchmarking and identify quality improvement targets for older trauma patients.

P250 Geriatric impairments associate with mortality and hospitalisations during follow-up in older IBD outpatients

Abstract Background We aimed evaluate the association between impairments found in a geriatric assessment and the risk for adverse outcomes in older patients with Inflammatory Bowel Disease (IBD). Methods In a prospective multicenter cohort study, a geriatric assessment was performed at baseline in 405 older (≥ 65 years) patients with IBD. Linear-and cox regression analyses were used to study the association between impairment in five geriatric domains measured in the geriatric assessment (somatic-, functional-, mental-, and social domain, physical capacity) and adverse outcomes occurring during 18 months of follow-up. Adverse outcomes were defined as all-cause-, acute-, and IBD-related hospitalisations and all-cause mortality. All analyses were adjusted for age, sex and biochemical disease activity (C-reactive protein ≥10 mg/L and/or fecal calprotectin ≥250 μg/g). Results Of 405 patients at baseline (median age: 70 years), 11 patients (2.7%) died and follow-up was conducted in 356 patients (87.9%). During 18 months, 136 all-cause hospitalizations occurred in 96 patients (23.7%), of which 103 (75.7%) were acute, occurring in 74 patients (18.3%). Forty-one hospitalizations (30.1%) in 28 patients (6.9%) were IBD-related. The number of impaired domains at baseline was independently associated with mortality (p=0.001, B=2.76), all-cause hospitalisation (p=0.016, B=1.28) and acute hospitalisation (p=0.02, B=1.3), but not with IBD-related hospitalisation (p=0.06, B=1.37). On domain level, mortality was associated with impaired mental- (p=0.002, B=8.9) and physical domains (p=0.006, B=9.5), all-cause hospitalisation with an impaired somatic domain (p=0.002, B=2.13), and acute hospitalisation with an impaired somatic domain (p=0.02, B=2.49). Conclusion Geriatric impairments in geriatric assessment are independently associated with adverse outcomes in older patients with IBD, including an increased risk of mortality, all-cause and acute hospitalizations. Therefore, this study provides the first prospective evidence for the predictive value of the geriatric assessment, enhancing risk stratification in older patients with IBD.

Viewpoint on "The Frail Scale - A Risk Stratification in Older Patients with Acute Coronary Syndrome" [Response to Letter

Viewpoint on "The Frail Scale - A Risk Stratification in Older Patients with Acute Coronary Syndrome" [Response to Letter

Prognostic impact of cachexia by multi-assessment in older adults with heart failure: FRAGILE-HF cohort study.

Cachexia substantially impacts the prognosis of patients with heart failure (HF); however, there is no standard method for cachexia diagnosis. This study aimed to investigate the association of Evans's criteria, consisting of multiple assessments, with the prognosis of HF in older adults. This study is a secondary analysis of the data from the FRAGILE-HF study, a prospective multicentre cohort study that enrolled consecutive hospitalized patients aged ≥65years with HF. Patients were divided into two groups: the cachexia and non-cachexia groups. Cachexia was defined according to Evans's criteria by assessing weight loss, muscle weakness, fatigue, anorexia, a decreased fat-free mass index and an abnormal biochemical profile. The primary outcome was all-cause mortality, as assessed in the survival analysis. Cachexia was present in 35.5% of the 1306 enrolled patients (median age [inter-quartile range], 81 [74-86] years; 57.0% male); 59.6%, 73.2%, 15.6%, 71.0%, 44.9% and 64.6% had weight loss, decreased muscle strength, a low fat-free mass index, abnormal biochemistry, anorexia and fatigue, respectively. All-cause mortality occurred in 270 patients (21.0%) over 2years. The cachexia group (hazard ratio [HR], 1.494; 95% confidence interval [CI], 1.173-1.903; P=0.001) had a higher mortality risk than the non-cachexia group after adjusting for the severity of HF. Cardiovascular and non-cardiovascular deaths occurred in 148 (11.3%) and 122 patients (9.3%), respectively. The adjusted HRs for cachexia in cardiovascular mortality and non-cardiovascular mortality were 1.456 (95% CI, 1.048-2.023; P=0.025) and 1.561 (95% CI, 1.086-2.243; P=0.017), respectively. Among the cachexia diagnostic criteria, decreased muscle strength (HR, 1.514; 95% CI, 1.095-2.093; P=0.012) and low fat-free mass index (HR, 1.424; 95% CI, 1.052-1.926; P=0.022) were significantly associated with high all-cause mortality, but there was no significant association between weight loss alone (HR, 1.147; 95% CI, 0.895-1.471; P=0.277) and all-cause mortality. Cachexia evaluated by multi-assessment was present in one third of older adults with HF and was associated with a worse prognosis. A multimodal assessment of cachexia may be helpful for risk stratification in older patients with HF.

Viewpoint on "The Frail Scale - A Risk Stratification in Older Patients with Acute Coronary Syndrome" [Letter

Viewpoint on "The Frail Scale - A Risk Stratification in Older Patients with Acute Coronary Syndrome" [Letter

The Frail Scale - A Risk Stratification in Older Patients with Acute Coronary Syndrome.

The aim of this study was to explore the impact of frailty on in-hospital adverse outcomes and net adverse clinical events (NACE) in older patients with acute coronary syndrome. This observational study included elderly patients (≥60 years old), diagnosed with acute coronary syndrome (ACS) at admission from February 2021 to August 2021. The primary outcome was net adverse clinical events (NACE) defined as a composite of all-cause mortality, stroke, and major bleeding. Secondary outcome was in-hospital adverse outcomes including arrhythmia, acquired pneumonia, stroke, major bleeding, and all-cause mortality. Frailty was assessed using the Frail scale (FS). Data about socio-demographics, comorbidities, body mass index, ACS type, coronary angiography, left ventricular ejection fraction, and length of hospital stay were also collected. Univariate and multivariate logistic regressions were employed to identify the potential association between frailty and outcomes. Of the 116 ACS patients, 38 patients were frail (32.76%). Frail subjects were more often female (50%) and older (p < 0.01) and had higher rates of in-hospital adverse outcomes (OR = 2.37, p = 0.05) and NACE (OR = 7.12; p < 0.01). In univariate analysis, the increased frail score was significantly associated with increased odds of NACE (unadjusted OR = 1.98, 95% CI 1.17-3.35 for each score increase in Frail Score). In multivariable logistic regression, models controlling for age, gender, PCI, LVEF, and coronary angiography (adjusted OR 2.19, 95% CI 1.12-4.29 for each score increase in Frail Score). This study revealed the reference data of frailty assessment in older patients with ACS in Vietnam. Our result indicated that over 30% of ACS older patients presented with frailty which was associated with an increased risk of in-hospital adverse outcomes and NACE. This study also provided promising information about the simple FRAIL scale's potential role in the risk stratification of older patients with ACS.

Exploring biomarkers in routine diagnostics for the risk stratification of older patients in the Chest Pain Unit: a prospective cohort study

ObjectivesThis study aims to estimate the association of the often, in daily clinical practice, used biological age-related biomarkers high-sensitivity troponin-T (hs-TnT), C reactive protein (CRP) and haemoglobin (Hb) with all-cause...

Red cell distribution width–A mortality predictor in older adults with proximal femoral fracture

Background: Identifying elderly patients with proximal femoral fractures (PFF) who are at risk of postoperative mortality may influence the treatment decision-making process. The purpose of this study was to examine whether red blood cell distribution width (RDW) can serve as a predictor of postoperative mortality in these patients. Methods: A retrospective cohort study of electronic medical records at a single tertiary care hospital over a 3-year period between 2015 and 2018. We reviewed the records of 1574 patients aged > 65 years who underwent surgical treatment for PFF and who's preoperative RDW levels were available. Data collected consisted of patient demographics, underlying illnesses at the time of admission, type of procedure performed as well as postoperative mortality and complications over the course of a 1-year follow-up period. The cohort was then divided into two groups based on their RDW levels at the time of admission: low (<14.5%) and high (>14.5%). Results: The mean age was 90.77±1.87 years; 68.7% were women. Majority of patients (69.1%) underwent closed reduction internal fixation; 414 (26.4%) underwent hemiarthroplasty, and 71 (4.5%) had total hip arthroplasty. At admission, 576 patients (36.6%) had high RDW levels and 998 (63.4%) had low RDW levels. There were no statistically significant differences between the groups with regard to age, gender, type of surgery, or duration. Patients with high RDW had more co-morbidities (p<0.001) and more abnormal laboratory test results when compared to patients with low RDW. Overall mortality rate within 1-year post-surgery was 17.5% (276 patients). All-cause mortality was greater for patients with high baseline RDW, at 3 months (p = 0.001), 6 months (p<0.0001), and 1-year post-surgery (p<0.0001). Forty-four (2.8%) patients had surgical site infection (SSI) without any significant association to baseline RDW levels. Conclusions: Preoperative RDW levels, when combined with clinical and laboratory findings, may help to improve the risk stratification of older patients who are candidates for PFF. With further research, a treatment algorithm could be developed to potentially identify patients at high risk of preoperative mortality, allowing for more conservative management.

Telehealth Management and Risk Stratification of Older Patients With Chronic Heart Failure During COVID-19 Pandemic: Prognostic Evaluation of the TeleHFCovid19-Score.

ObjectivesTo evaluate 6-month risk stratification capacity of the newly developed TeleHFCovid19-Score for remote management of older patients with heart failure (HF) during the coronavirus disease 2019 pandemic.DesignMonocentric observational prospective study.Setting and ParticipantsOlder HF outpatients remotely managed during the first pandemic wave.MethodsThe TeleHFCovid19-Score (0-29) was obtained by an ad hoc developed multiparametric standardized questionnaire administered during telephone visits to older HF patients (and/or caregivers) followed at our HF clinic. Questions were weighed on the basis of clinical judgment and review of current HF literature. According to the score, patients were divided in progressively increasing risk groups: green (0-3), yellow (4-8), and red (≥9).ResultsA total of 146 patients composed our study population: at baseline, 112, 21, and 13 were classified as green, yellow, and red, respectively. Mean age was 81±9 years, and women were 40%. Compared to patients of red and yellow groups, those in the green group had a lower use of high-dose loop diuretics (P < .001) or thiazide-like diuretics (P = .027) and had reported less frequently dyspnea at rest or for basic activities, new or worsening extremity edema, or weight increase (all P < .001). At 6 months, compared with red (62.2%) and yellow patients (33.3%), green patients (8.9%) presented a significantly lower rate of the composite outcome of cardiovascular death and/or HF hospitalization (P < .001). Moreover, receiver operating characteristic curve analysis showed a high sensibility and specificity of our score at 6 months (area under the curve = 0.789, 95% CI 0.682-0.896, P < .001) with a score <4.5 (very close to green group cutoff) that identified lower-risk subjects.Conclusions and ImplicationsThe TeleHFCovid19-Score was able to correctly identify patients with midterm favorable outcome. Therefore, our questionnaire might be used to identify low-risk chronic HF patients who could be temporarily managed remotely, allowing to devote more efforts to the care of higher-risk patients who need closer and on-site clinical evaluations.

Exploring biomarkers of age in routine diagnostics for the risk stratification of older patients in the emergency department

Abstract Objectives To estimate the association of the routinely applied biological age-related biomarkers hs-TnT, CRP and Hemoglobin (Hb) with mortality for the purpose of older patient's risk stratification in the emergency department (ED). Design Exploratory, prospective cohort study with a follow-up at 2.5 years after recruitment start. Setting and participants A cardiological emergency department (ED), chest pain unit, of our University Hospital. N=256 cardiological ED patients with a minimum age of 70 years and with an expected life-expectancy above 24h. Methods Data from the hospital files were supplemented by a questionnaire. Patients were followed-up for mortality by requesting registry office information. Results Among N=256 patients 63 died over the follow-up period. Positive results in each of the three biomarkers alone as well as the combination were associated with increased all-cause mortality at follow-up. The number of positive age-related biomarkers appeared to be strongly indicative of the risk of mortality, even when controlled for major confounders (age, sex, BMI, creatinine clearance, and comorbidity). Conclusion and implications In older ED patients, biomarkers explicitly related to biological aging processes such as hs-TnT, CRP and Hb were independently of each other as well as combined associated with an increased risk of all-cause mortality. Thus, they may have the potential to be used to supplement the general risk stratification of older patients in the ED. Validation of the results in a large dataset is needed. Funding Acknowledgement Type of funding sources: Foundation. Main funding source(s): Robert Bosch Foundation, Stuttgart, Germany Kaplan-Meier curves with 95% CIKaplan-Meier curves for patients grouped

Clinical relevance of spectral tissue Doppler-derived E/e′ in older patients with preserved ejection fraction

BackgroundThe E/e′ index measured in spectral tissue Doppler is included in the recommendations for the diagnosis by transthoracic Doppler echocardiography of left ventricular diastolic dysfunction and heart failure with preserved ejection fraction. While E/e′ is influenced by age in healthy individuals, no studies have evaluated this index in elderly patients. This study addressed the clinical relevance of E/e′ in assessment of left ventricular diastolic function in elderly patients with preserved ejection fraction and its relevance from both a diagnostic and prognostic perspective based on the existing literature. MethodsA total of 76 patients≥70years of age were prospectively included. The analysis of left ventricular diastolic function was adapted from the 2016 ASE/EACVI recommendations without consideration of E/e′. ResultsThe mean age was 85years. In all, 42 patients had moderate-to-severe diastolic dysfunction (elevated left atrial pressure). Mean E/e′ was significantly correlated with diastolic function (r=0.58, P<0.001). Mean E/e′>13.3 had a sensitivity of 86% and a specificity of 91% in the diagnosis of moderate-to-severe diastolic dysfunction (AUC: 0.92). E/(e′xs′) (AUC: 0.89) and NT pro-BNP (AUC: 0.80) did not perform better than E/e′. The existing literature offers large body of evidence that E/e′ provides essential diagnostic and prognostic information in older patients with cardiovascular disease. ConclusionE/e′ is accurate in the diagnosis of significant diastolic dysfunction, in the diagnosis of heart failure with preserved ejection fraction and in risk stratification in older patients with cardiovascular disease.

P097 Abnormal frailty screening is independently associated with both all-cause and disease-related hospital admissions in older patients with inflammatory bowel diseases

Abstract Background Frailty could be useful for risk stratification in older patients with Inflammatory Bowel Diseases (IBD). However, no prospective evidence is yet available. We aimed to assess how frailty screening associates with hospital admissions and functional and (health related) quality of life (HR)QoL decline. Methods This is a prospective multicenter cohort study. Consecutive IBD patients aged ≥65 years were included at outpatient departments and infusion centers in six hospitals. Clinical disease activity was assessed through Harvey Bradshaw Index (HBI) or partial Mayo Score (pMS) (remission: HBI&amp;lt;5 or pMS&amp;lt;2), biochemical disease activity by C-reactive protein ≥10 mg/L and/or calprotectin ≥250 µg/g. Frailty screening was performed by Geriatric 8 (G8) questionnaire (abnormal: ≤14). At 18 months, data regarding hospital admissions and mortality were retrieved from medical records and, when possible, verified during follow-up visits. Functional status (Katz Index of Independence in Activities of Daily Living (ADL) and Lawton Instrumental Activities of Daily Living (IADL)) and (HR)QoL (short Inflammatory Bowel Disease Questionnaire and EuroQol-5D) were assessed at baseline and follow-up. Hospital admissions were analyzed with Kaplan Meier and Cox regression, functional and (HR)QoL decline with logistic regression. Analyses were corrected for age and biochemical disease activity. Results 405 patients were included, median age 70 (IQR 67–74), 85 (21%) clinical disease activity, 93 (23%) biochemical disease activity and 196 (48%) abnormal G8. Until February 2021, 293 (72%) patients were eligible for follow-up: 255 participated in follow-up visits, 38 patients did not (15 not reachable, 16 not willing, 7 died). 74 all-cause and 33 IBD-related hospital admissions occurred. Abnormal G8 was associated with occurrence of both all-cause (adjusted HR 3.9, 95%CI 1.9–7.8, p&amp;lt;.001, Fig. 1) and IBD-related hospital admissions (adjusted HR 4.1, 95% CI 1.4–12.3, p=0.012, Fig. 2). Seven patients died during follow-up; six had abnormal G8. 19 (37%) out of 51 patients with both active biochemical disease and abnormal G8 were hospitalized compared to 4 (14%) out of 29 patients with active disease and normal G8 (p=.026). Abnormal G8 associated with functional (IADL: aOR 3.0, 95% CI 1.3–6.9, P.009, ADL: aOR 1.6, 95% CI 0.7–3.3, p.241) and QoL decline (EQ5D: aOR 2.4, 95% CI 1.4–4.3, p.002), not with HRQoL (sIBDQ: aOR 1.3, 95% CI 0.8–2.2, p=.336). Conclusion Abnormal frailty screening independently associates with both all-cause and IBD-related hospital admissions and with functional and QoL decline. Therefore, we provide the first prospective evidence for frailty screening as a useful risk stratification tool in IBD.

Frailty Predicts Adverse Outcomes in Older Patients Undergoing Transcatheter Aortic Valve Replacement (TAVR): From the National Inpatient Sample

ObjectiveWe aimed to study the impact of frailty on the outcome of transcatheter aortic valve replacement (TAVR) procedures. MethodsThe National Inpatient Sample (NIS) database was queried for all patients aged ≥65 years who underwent a TAVR procedure during the years 2016–2017. Frailty was measured using a previously validated Hospital Frailty Risk Score (HFRS) scoring system. The score is ICD-10 code based; thus, it can be calculated from an administrative database. Study outcomes were in-hospital all-cause mortality, peri-procedural complications, length of stay, and total cost. Outcomes were modeled using logistic regression for binary outcomes and generalized linear regression for continuous outcomes. ResultsThere were 84,750 patients included in the study. These patients were divided into low-risk (61,050), intermediate-risk (22,955), and high-risk (744), based on average frailty index scores of 2, 7, and 16.8, respectively. On multivariable analysis, the HFRS correlated with increased odds for mortality with an adjusted odd ratio (a-OR) of 1.25 (95% CI: 1.22–1.29, p < 0.001), myocardial infarction [a-OR 1.10 (95% CI: 1.07–1.13, p < 0.001)], pericardiocentesis [a-OR 1.16 (95% CI: 1.12–1.20, p < 0.001)], pacemaker insertion [a-OR 1.06 (95% CI: 1.04–1.08, p < 0.001)], blood transfusion [a-OR 1.14 (95% CI: 1.11–1.16, p < 0.001)], vascular complications [a-OR 1.05 (95% CI: 1.00–1.09, p = 0.03)], longer length of stay [a-MR 1.10 (95% CI: 1.10–1.11, p < 0.001)] and higher cost [a-MR: 1.04 (95% CI: 1.03–1.04, p < 0.001)]. ConclusionThe HFRS can be utilized in the risk stratification of older patients undergoing TAVR.

Pre-operative physical performance as a predictor of in-hospital outcomes in older patients undergoing elective cardiac surgery

ObjectiveRisk stratification of cardiac surgery patients is usually based on the Society of Thoracic Surgeons (STS) score, that has limited predictive value in older persons. We aimed assessing whether the Short Physical Performance Battery (SPPB) improves, beyond the STS score, assessment of hospital prognosis in older patients undergoing elective cardiac surgery. MethodsAll patients aged 75+ years referred for elective cardiac surgery to Careggi University Hospital (Florence, Italy) from April 2013 to March 2017 were evaluated pre-operatively. Participants were classified according to the STS-Predicted Risk Of Mortality (STS-PROM): low (<4%), intermediate (4 to 8%), and high risk (>8%). Primary study outcomes were hospital mortality and STS-defined major morbidity. Length of hospital stay was an additional outcome. ResultsOut of 235 participants (females: 46.5%; mean age: 79.6 years), 144 (61.3%) were at low, 67 (28.5%) at intermediate and 24 (10.2%) at high risk, based on the STS-PROM. SPPB (mean±SEM) was 8.8 ± 0.2, 7.0 ± 0.5, and 6.0 ± 0.8 in participants at low, intermediate, and high risk, respectively (p<0.001). The primary outcome occurred in 62 participants (26.4%). In low-risk participants, the SPPB score predicted the primary endpoint (adjusted OR 0.77, 95% CI 0.66–0.89 per each point increase; p<0.001) controlling for STS-Major Morbidity or Operative Mortality (STS-MM) score. This result was not observed in the intermediate-high risk group. ConclusionsSPPB predicts mortality and major morbidity in older patients undergoing elective cardiac surgery, classified as low risk with the STS risk score. The SPPB, applied preoperatively, might improve risk stratification in older patients undergoing elective cardiac surgery.

Hospital-Acquired Functional Decline and Clinical Outcomes in Older Patients Undergoing Transcatheter Aortic Valve Implantation.

This study aimed to assess the relationship between hospital-acquired functional decline and the risk of mid-term all-cause death in older patients undergoing transcatheter aortic valve implantation (TAVI).Methods and Results:In total, 463 patients (mean age 85 years, interquartile range [IQR]: 82, 88) undergoing elective TAVI at Sakakibara Heart Institute between 2010 and 2018, who were followed up for 3 years, were enrolled in the study. Hospital-acquired functional decline after TAVI, which was defined by at least a 1-point decrease on the Short Physical Performance Battery before discharge compared to the preoperative score, was assessed. A total of 113 patients (24.4%) showed hospital-acquired functional decline after TAVI, and 50 (11.3%) patients died over a mean follow-up period of 1.9±0.8 years. Kaplan-Meier survival curves indicated that hospital-acquired functional decline was significantly associated with all-cause mortality (log-rank test, P=0.001). On multivariate Cox regression analysis, hospital-acquired functional decline was associated with a higher risk of all-cause mortality (OR 2.108, 95% CI 1.119-3.968, P=0.021) independent of sex, body mass index, advanced chronic kidney disease, and preoperative frailty, as assessed by the modified essential frail toolkit. Hospital-acquired functional decline is associated with mid-term all-cause mortality in older patients following TAVI. Trajectory of functional status is a vital sign, and it is useful for risk stratification in older patients following TAVI.

SPMSQ for risk stratification of older patients in the emergency department : An exploratory prospective cohort study.

BackgroundRisk stratification of older patients in the emergency department (ED) is seen as a promising and efficient solution for handling the increase in demand for geriatric emergency medicine. Previously, the predictive validity of commonly used tools for risk stratification, such as the identification of seniors at risk (ISAR), have found only limited evidence in German geriatric patient samples. Given that the adverse outcomes in question, such as rehospitalization, nursing home admission and mortality, are substantially associated with cognitive impairment, the potential of the short portable mental status questionnaire (SPMSQ) as a tool for risk stratification of older ED patients was investigated.ObjectiveTo estimate the predictive validity of the SPMSQ for a composite endpoint of adverse events (e.g. rehospitalization, nursing home admission and mortality).MethodThis was a prospective cohort study with 260 patients aged 70 years and above, recruited in a cardiology ED. Patients with a likely life-expectancy below 24 h were excluded. Follow-up examinations were conducted at 1, 3, 6 and 12 month(s) after recruitment.ResultsThe SPMSQ was found to be a significant predictor of adverse outcomes not at 1 month (area under the curve, AUC 0.55, 95% confidence interval, CI 0.46–0.63) but at 3 months (AUC 0.61, 95% CI 0.54–0.68), 6 months (AUC 0.63, 95% CI 0.56–0.70) and 12 months (AUC 0.63, 95% CI 0.56–0.70) after initial contact.ConclusionFor longer periods of observation the SPMSQ can be a predictor of a composite endpoint of adverse outcomes even when controlled for a range of confounders. Its characteristics, specifically the low sensitivity, make it unsuitable as an accurate risk stratification tool on its own.Electronic supplementary materialThe online version of this article (10.1007/s00391-019-01626-z) contains supplementary material, which is available to authorized users.

P5983Pre-operative physical performance as an independent predictor of in-hospital outcomes in older patients undergoing elective cardiac surgery

Abstract Introduction Risk stratification of patients candidate to cardiac surgery is usually based on the Society of Thoracic Surgeons (STS) score or on the Euroscore II. However, these risk scores has limited predictive value in elderly patients. Purpose We conducted a study to determine whether the Short Physical Performance Battery (SPPB), a tool assessing physical performance, predicts hospital death and major morbidity, beyond STS risk score. The outcome was a composite end-point as defined by STS Major Morbidity or Operative Mortality (STS-MM) in STS Risk Model Outcomes: operative mortality, stroke, renal failure, prolonged mechanical ventilation, deep sternal wound infection, and reoperation. Methods In this prospective, single-center, cohort, hospital-based study, conducted at Careggi University Hospital, Florence, Italy, all patients aged 75+ years referred for an elective coronary aortic by-pass grafting, valvular surgery or combined cardiac surgery were evaluated pre-operatively. Assessment included SPPB, cognitive and functional status and evaluation of comorbidity. Patients receiving emergency/urgent cardiac surgery or a procedure not considered in the STS risk score calculator, who reported previous cardiac surgery or were clinically unstable were excluded. Participants were classified according to the STS-Predicted Risk Of Mortality (STS-PROM) as at low (&lt;4%), intermediate (4 to 8%) or high risk (&gt;8%). Results Out of 250 participants (females: 48.4%; mean age: 79.9 years), 148 (59.2%) were at low, 73 (29.2%) at intermediate and 29 (11.6%) at high risk, based on the STS-PROM. Mean±SEM SPPB score was 8.8±0.2, 7.1±0.4 and 6.0±0.7 in participants at low, intermediate, and high risk, respectively (p&lt;0.001). The outcome occurred in 67 subjects (26.8%). SPPB score predicted the outcome in the entire study sample, controlling for STS-MM score, CKD, and anaemia (adjusted OR: 0.89, 95% CI 0.81–0.98 per each point increase; p 0.017). When analyses were repeated separately in participants with STS-PROM indicative of low (&lt;4%) and in those at medium-high risk, the predictive value of SPPB was enhanced in the formers (adjusted OR 0.73, 95% CI 0.62–0.86 per each point increase; p&lt;0.001- controlling for STS score), whereas was lost in the latter. An alternative model was subsequently tested, where STS score was not included and peripheral artery disease and creatinine (variables contributing to the STS score) were individually entered: SPPB was confirmed as a significant predictor also in this model, controlling for anaemia, peripheral artery disease, and creatinine. The corresponding AUC was 0.813 (Figure 1). Figure 1 Conclusions SPPB predicts mortality and major morbidity in older patients undergoing elective cardiac surgery, in particular in those classified as low-risk with the STS risk score. Use of SPPB should therefore be recommended to improve preoperative risk stratification of older patients.

Prognostic and Biologic Relevance of Clinically Applicable Long Noncoding RNA Profiling in Older Patients with Cytogenetically Normal Acute Myeloid Leukemia.

We have previously shown that expression levels of 48 long noncoding RNAs (lncRNA) can generate a prognostic lncRNA score that independently associates with outcome of older patients with cytogenetically normal acute myeloid leukemia (CN-AML). However, the techniques used to identify and measure prognostic lncRNAs (i.e., RNA sequencing and microarrays) are not tailored for clinical testing. Herein, we report on an assay (based on the nCounter platform) that is designed to produce targeted measurements of prognostic lncRNAs in a clinically applicable manner. We analyzed a new cohort of 76 older patients with CN-AML and found that the nCounter assay yielded reproducible measurements and that the lncRNA score retained its prognostic value; patients with high lncRNA scores had lower complete remission (CR) rates (P = 0.009; 58% vs. 87%), shorter disease-free (P = 0.05; 3-year rates: 0% vs. 21%), overall (OS; P = 0.02, 3-year rates: 10% vs. 29%), and event-free survival (EFS; P = 0.002, 3-year rates: 0% vs. 18%) than patients with low lncRNA scores. In multivariable analyses, the lncRNA score independently associated with CR rates (P = 0.02), OS (P = 0.02), and EFS (P = 0.02). To gain biological insights, we examined our initial cohort of 71 older patients with CN-AML, previously analyzed with RNA sequencing. Genes involved in immune response and B-cell receptor signaling were enriched in patients with high lncRNA scores. We conclude that clinically applicable lncRNA profiling is feasible and potentially useful for risk stratification of older patients with CN-AML. Furthermore, we identify potentially targetable molecular pathways that are active in the high-risk patients with high lncRNA scores.

Transplantation related toxicity and mortality in older autologous hematopoietic cell transplantation recipients.

With advances in supportive care, autologous hematopoietic cell transplant (AHCT) is increasingly being performed for patients older than 60 years. We analyzed patients receiving an AHCT for multiple myeloma or lymphoma in a contemporary cohort (2010-2012), with consistent treatment and supportive care and compared outcomes [CTCAE grade 3-5 toxicities, nonrelapse mortality (NRM) and overall-survival (OS)] of younger (40-59 years, n = 77) versus older (≥60 years, n = 67) recipients. The proportion of patients with neutropenic infections was higher in the older group (64% vs. 44%; P = 0.02). The proportion of patients with any grade 3-5 toxicity was also higher in the older group (84% vs. 67%, P = 0.03). In multivariate analysis, older age was significantly associated with higher odds (OR: 2.57, 95% CI:1.09-6.05) of grade 3-5 toxicity. The NRM was 3% (older) vs. 0% (younger) at 1 year. The probability of OS at 2 years was lower in the older group (76% vs. 90%, P = 0.04). Though AHCT can be performed safely in older recipients, the higher toxicity and slightly higher NRM in this population needs attention. Studies focusing on risk-stratification in older patients would further help predict toxicity. Further studies addressing enhanced supportive care needs for older patients who are most likely to benefit are indicated.