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Journal ArticleDOI

Predictors of functional decline in elderly patients undergoing transcatheter aortic valve implantation (TAVI)

TL;DR: Over a 6-month period, functional status worsened only in a minority of patients surviving TAVI, and the frailty index, but not established risk scores, was predictive of functional decline.
Abstract: Aims This study aimed to assess functional course in elderly patients undergoing transcatheter aortic valve implantation (TAVI) and to find predictors of functional decline. Methods and results In this prospective cohort, functional course was assessed in patients ≥70 years using basic activities of daily living (BADL) before and 6 months after TAVI. Baseline EuroSCORE, STS score, and a frailty index (based on assessment of cognition, mobility, nutrition, instrumental and basic activities of daily living) were evaluated to predict functional decline (deterioration in BADL) using logistic regression models. Functional decline was observed in 22 (20.8%) of 106 surviving patients. EuroSCORE (OR per 10% increase 1.18, 95% CI: 0.83-1.68, P = 0.35) and STS score (OR per 5% increase 1.64, 95% CI: 0.87-3.09, P = 0.13) weakly predicted functional decline. In contrast, the frailty index strongly predicted functional decline in univariable (OR per 1 point increase 1.57, 95% CI: 1.20-2.05, P = 0.001) and bivariable analyses (OR: 1.56, 95% CI: 1.20-2.04, P = 0.001 controlled for EuroSCORE; OR: 1.53, 95% CI: 1.17-2.02, P = 0.002 controlled for STS score). Overall predictive performance was best for the frailty index [Nagelkerke's R(2) (NR(2)) 0.135] and low for the EuroSCORE (NR(2) 0.015) and STS score (NR(2) 0.034). In univariable analyses, all components of the frailty index contributed to the prediction of functional decline. Conclusion Over a 6-month period, functional status worsened only in a minority of patients surviving TAVI. The frailty index, but not established risk scores, was predictive of functional decline. Refinement of this index might help to identify patients who potentially benefit from additional geriatric interventions after TAVI.

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Citations
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Journal ArticleDOI
TL;DR: This work sought to synthesize the existing body of evidence and offer a perspective on how to integrate frailty into clinical practice and contribute valuable prognostic insights incremental to existing risk models and assists clinicians in defining optimal care pathways for their patients.

817 citations


Cites background or result from "Predictors of functional decline in..."

  • ...This is in slight contrast to the TAVR experience at Bern University (73,74), in which the vast majority of patients were able to complete the timed-up-and-go test (which requires standing up from a chair, walking 3 m, and turning around) and 61% of patients were able to do so faster than the usual cutoff of 20 s....

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  • ...Schoenenberger, 2012 (73) 119 Prospective cohort of patients undergoing TAVR In-house scale 3/7 50% 6-month ADL change 1: 31....

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Journal ArticleDOI
TL;DR: Evidence is found that frailty in older-old and oldest-old surgical patients predicts post-operative mortality, complications, and prolonged length of stay, and frailty assessment may be a valuable tool in peri-operative assessment.
Abstract: As the population ages, increasing numbers of older adults are undergoing surgery. Frailty is prevalent in older adults and may be a better predictor of post-operative morbidity and mortality than chronological age. The aim of this review was to examine the impact of frailty on adverse outcomes in the ‘older old’ and ‘oldest old’ surgical patients. A systematic review was undertaken. Electronic databases from 2010 to 2015 were searched to identify articles which evaluated the relationship between frailty and post-operative outcomes in surgical populations with a mean age of 75 and older. Articles were excluded if they were in non-English languages or if frailty was measured using a single marker only. Demographic data, type of surgery performed, frailty measure and impact of frailty on adverse outcomes were extracted from the selected studies. Quality of the studies and risk of bias was assessed by the Epidemiological Appraisal Instrument. Twenty-three studies were selected for the review and they were assessed as medium to high quality. The mean age ranged from 75 to 87 years, and included patients undergoing cardiac, oncological, general, vascular and hip fracture surgeries. There were 21 different instruments used to measure frailty. Regardless of how frailty was measured, the strongest evidence in terms of numbers of studies, consistency of results and study quality was for associations between frailty and increased mortality at 30 days, 90 days and one year follow-up, post-operative complications and length of stay. A small number of studies reported on discharge to institutional care, functional decline and lower quality of life after surgery, and also found a significant association with frailty. There was strong evidence that frailty in older-old and oldest-old surgical patients predicts post-operative mortality, complications, and prolonged length of stay. Frailty assessment may be a valuable tool in peri-operative assessment. It is possible that different frailty tools are best suited for different acuity and type of surgical patients. The association between frailty and return to pre-morbid function, discharge destination, and quality of life after surgery warrants further research.

605 citations


Additional excerpts

  • ...Functional Decline Quality [ref] Q1 [20] Q2 [28]...

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Journal ArticleDOI
03 Mar 2016
TL;DR: The introduction of transcatheter AVR in the past decade has been a transformative therapeutic innovation for patients at high or prohibitive risk for surgical valve replacement, and this new technology might extend to lower-risk patients in the near future.
Abstract: Calcific aortic stenosis (AS) is the most prevalent heart valve disorder in developed countries. It is characterized by progressive fibro-calcific remodelling and thickening of the aortic valve leaflets that, over years, evolve to cause severe obstruction to cardiac outflow. In developed countries, AS is the third-most frequent cardiovascular disease after coronary artery disease and systemic arterial hypertension, with a prevalence of 0.4% in the general population and 1.7% in the population >65 years old. Congenital abnormality (bicuspid valve) and older age are powerful risk factors for calcific AS. Metabolic syndrome and an elevated plasma level of lipoprotein(a) have also been associated with increased risk of calcific AS. The pathobiology of calcific AS is complex and involves genetic factors, lipoprotein deposition and oxidation, chronic inflammation, osteoblastic transition of cardiac valve interstitial cells and active leaflet calcification. Although no pharmacotherapy has proved to be effective in reducing the progression of AS, promising therapeutic targets include lipoprotein(a), the renin-angiotensin system, receptor activator of NF-κB ligand (RANKL; also known as TNFSF11) and ectonucleotidases. Currently, aortic valve replacement (AVR) remains the only effective treatment for severe AS. The diagnosis and staging of AS are based on the assessment of stenosis severity and left ventricular systolic function by Doppler echocardiography, and the presence of symptoms. The introduction of transcatheter AVR in the past decade has been a transformative therapeutic innovation for patients at high or prohibitive risk for surgical valve replacement, and this new technology might extend to lower-risk patients in the near future.

532 citations

Journal ArticleDOI
TL;DR: A brief 4-item scale encompassing lower-extremity weakness, cognitive impairment, anemia, and hypoalbuminemia outperformed other frailty scales and is recommended for use in this setting.

509 citations


Cites background from "Predictors of functional decline in..."

  • ...Lower-extremity muscle weakness, malnutrition, and cognitive impairment played a prominent role in newer scales, which were shown in small studies of 100 to 244 patients to have a predictive effect on mortality and disability 6 to 12 months after TAVR (18,19,33)....

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  • ...SAVR isolated 179 (18) 173 (20) 6 (4) SAVR with bypass 195 (19) 175 (20) 20 (14)...

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  • ...The Bern scale consists of 6 items for a composite score of 0 to 7: gait speed, mobility, cognition, nutrition, ADL and IADL disability (17,18)....

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  • ...002 Cognitive impairment† 179 (18) 125 (14) 54 (37) <0....

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  • ...08 Weight loss 179 (18) 146 (17) 33 (23) 0....

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Journal ArticleDOI
TL;DR: Patients deemed frail, determined using an objective assessment tool, have a higher likelihood of experiencing mortality, morbidity, functional decline, and MACCE following cardiac surgery, regardless of definition.

301 citations


Cites background or methods or result from "Predictors of functional decline in..."

  • ...In the studies investigating TAVR and frailty, patients were older and had increased EuroSCOREs, which may account for the increase in the hazard ratios and ORs.(15,16) Patients who are undergoing TAVR are typically selected with the notion that they would not fair well with a conventional surgical aortic valve replacement....

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  • ...Two studies(14,15) used a modified geriatric baseline examination, whereas another looked at the Katz Index of Independence in Activities of Daily Living, independence in ambulation, and previous diagnosis of dementia.(16) Afilalo and colleagues(2) looked at 4 scales for comparison....

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  • ...3112 The Journal of Thoracic and Cardiovascular Sur Multidimensional Geriatric Assessment for determining frailty.(15,16) Both studies had parallel results, with 1 study(15) finding a significant association between frailty and functional decline (OR, 4....

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  • ...However transcatheter aortic valve implantation is used to treat severe aortic stenosis and is reserved for older patients who are deemed inoperable.15 In the studies investigating TAVR and frailty, patients were older and had increased EuroSCOREs, which may account for the increase in the hazard ratios and ORs.15,16 Patients who are undergoing TAVR are typically selected with the notion that they would not fair well with a conventional surgical aortic valve replacement.3 This could lead to a discrepancy when trying to apply the studies findings to those in a lower risk demographic.3...

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References
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Journal ArticleDOI
TL;DR: A simplified, scored form of the cognitive mental status examination, the “Mini-Mental State” (MMS) which includes eleven questions, requires only 5-10 min to administer, and is therefore practical to use serially and routinely.

76,181 citations

01 Jan 2002
TL;DR: The Mini-Mental State (MMS) as mentioned in this paper is a simplified version of the standard WAIS with eleven questions and requires only 5-10 min to administer, and is therefore practical to use serially and routinely.
Abstract: EXAMINATION of the mental state is essential in evaluating psychiatric patients.1 Many investigators have added quantitative assessment of cognitive performance to the standard examination, and have documented reliability and validity of the several “clinical tests of the sensorium”.2*3 The available batteries are lengthy. For example, WITHERS and HINTON’S test includes 33 questions and requires about 30 min to administer and score. The standard WAIS requires even more time. However, elderly patients, particularly those with delirium or dementia syndromes, cooperate well only for short periods.4 Therefore, we devised a simplified, scored form of the cognitive mental status examination, the “Mini-Mental State” (MMS) which includes eleven questions, requires only 5-10 min to administer, and is therefore practical to use serially and routinely. It is “mini” because it concentrates only on the cognitive aspects of mental functions, and excludes questions concerning mood, abnormal mental experiences and the form of thinking. But within the cognitive realm it is thorough. We have documented the validity and reliability of the MMS when given to 206 patients with dementia syndromes, affective disorder, affective disorder with cognitive impairment “pseudodementia”5T6), mania, schizophrenia, personality disorders, and in 63 normal subjects.

70,887 citations

Journal ArticleDOI
TL;DR: This study provides a potential standardized definition for frailty in community-dwelling older adults and offers concurrent and predictive validity for the definition, and finds that there is an intermediate stage identifying those at high risk of frailty.
Abstract: Background: Frailty is considered highly prevalent in old age and to confer high risk for falls, disability, hospitalization, and mortality. Frailty has been considered synonymous with disability, comorbidity, and other characteristics, but it is recognized that it may have a biologic basis and be a distinct clinical syndrome. A standardized definition has not yet been established. Methods: To develop and operationalize a phenotype of frailty in older adults and assess concurrent and predictive validity, the study used data from the Cardiovascular Health Study. Participants were 5,317 men and women 65 years and older (4,735 from an original cohort recruited in 1989-90 and 582 from an African American cohort recruited in 1992-93). Both cohorts received almost identical baseline evaluations and 7 and 4 years of follow-up, respectively, with annual examinations and surveillance for outcomes including incident disease, hospitalization, falls, disability, and mortality. Results: Frailty was defined as a clinical syndrome in which three or more of the following criteria were present: unintentional weight loss (10 lbs in past year), self-reported exhaustion, weakness (grip strength), slow walking speed, and low physical activity. The overall prevalence of frailty in this community-dwelling population was 6.9%; it increased with age and was greater in women than men. Four-year incidence was 7.2%. Frailty was associated with being African American, having lower education and income, poorer health, and having higher rates of comorbid chronic diseases and disability. There was overlap, but not concordance, in the cooccurrence of frailty, comorbidity, and disability. This frailty phenotype was independently predictive (over 3 years) of incident falls, worsening mobility or ADL disability, hospitalization, and death, with hazard ratios ranging from 1.82 to 4.46, unadjusted, and 1.29-2.24, adjusted for a number of health, disease, and social characteristics predictive of 5-year mortality. Intermediate frailty status, as indicated by the presence of one or two criteria, showed intermediate risk of these outcomes as well as increased risk of becoming frail over 3-4 years of follow-up (odds ratios for incident frailty = 4.51 unadjusted and 2.63 adjusted for covariates, compared to those with no frailty criteria at baseline). Conclusions: This study provides a potential standardized definition for frailty in community-dwelling older adults and offers concurrent and predictive validity for the definition. It also finds that there is an intermediate stage identifying those at high risk of frailty. Finally, it provides evidence that frailty is not synonymous with either comorbidity or disability, but comorbidity is an etiologic risk factor for, and disability is an outcome of, frailty. This provides a potential basis for clinical assessment for those who are frail or at risk, and for future research to develop interventions for frailty based on a standardized ascertainment of frailty.

16,255 citations


"Predictors of functional decline in..." refers background or methods in this paper

  • ...The advantage of this operational definition of frailty is the inclusion of cognitive function, an aspect not covered in other operational definitions of frailty.(27) However, prior to clinical use, additional research is needed to confirm the validity of this newly proposed index....

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  • ...Fifthly, frailty is a novel concept in geriatrics, and there is not yet a generally accepted operational definition of frailty in the literature.(27,28) In the present study, frailty was defined as an index based on validated instruments covering key subdomains related to frailty and disability in old age....

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  • ...According to existing literature, cognition, mobility, and nutritional status are the most commonly used components of frailty.(27,28) The frailty index of the present study was calculated as summary score from the following baseline components: 2 points were assigned, if MMSE was ,21 points; 1 point was assigned for each of the following: MMSE ≥ 21 and ,27 points, TUG ≥ 20 s, MNA , 12 points, BADL ≥ 1 limited activity, IADL ≥ 1 limited activity, and a pre-clinical mobility disability (defined as decreased frequency of walking 200 m and/or of climbing stairs during the preceding 6 months)....

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Journal ArticleDOI
TL;DR: Two scales first standardized on their own population are presented, one of which taps a level of functioning heretofore inadequately represented in attempts to assess everyday functional competence, and the other taps a schema of competence into which these behaviors fit.
Abstract: THE use of formal devices for assessing function is becoming standard in agencies serving the elderly. In the Gerontological Society's recent contract study on functional assessment (Howell, 1968), a large assortment of rating scales, checklists, and other techniques in use in applied settings was easily assembled. The present state of the trade seems to be one in which each investigator or practitioner feels an inner compusion to make his own scale and to cry that other existent scales cannot possibly fit his own setting. The authors join this company in presenting two scales first standardized on their own population (Lawton, 1969). They take some comfort, however, in the fact that one scale, the Physical Self-Maintenance Scale (PSMS), is largely a scale developed and used by other investigators (Lowenthal, 1964), which was adapted for use in our own institution. The second of the scales, the Instrumental Activities of Daily Living Scale (IADL), taps a level of functioning heretofore inadequately represented in attempts to assess everyday functional competence. Both of the scales have been tested further for their usefulness in a variety of types of institutions and other facilities serving community-resident older people. Before describing in detail the behavior measured by these two scales, we shall briefly describe the schema of competence into which these behaviors fit (Lawton, 1969). Human behavior is viewed as varying in the degree of complexity required for functioning in a variety of tasks. The lowest level is called life maintenance, followed by the successively more complex levels of func-

14,832 citations

Journal ArticleDOI
TL;DR: This study evaluated a modified, timed version of the “Get‐Up and Go” Test (Mathias et al, 1986) in 60 patients referred to a Geriatric Day Hospital and suggested that the timed “Up & Go’ test is a reliable and valid test for quantifying functional mobility that may also be useful in following clinical change over time.
Abstract: This study evaluated a modified, timed version of the "Get-Up and Go" Test (Mathias et al, 1986) in 60 patients referred to a Geriatric Day Hospital (mean age 79.5 years). The patient is observed and timed while he rises from an arm chair, walks 3 meters, turns, walks back, and sits down again. The results indicate that the time score is (1) reliable (inter-rater and intra-rater); (2) correlates well with log-transformed scores on the Berg Balance Scale (r = -0.81), gait speed (r = -0.61) and Barthel Index of ADL (r = -0.78); and (3) appears to predict the patient's ability to go outside alone safely. These data suggest that the timed "Up & Go" test is a reliable and valid test for quantifying functional mobility that may also be useful in following clinical change over time. The test is quick, requires no special equipment or training, and is easily included as part of the routine medical examination.

12,004 citations

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