Publish in this journal
Journal Information
Vol. 73. Issue 4.
Pages 336-338 (April 2020)
Vol. 73. Issue 4.
Pages 336-338 (April 2020)
Scientific letter
Full text access
Comprehensive geriatric assessment in older patients with severe aortic stenosis: usefulness in detecting problems and planning interventions
Valoración geriátrica integral de pacientes mayores con estenosis aórtica grave: utilidad en la detección de problemas y planificación de intervenciones
Visits
2847
José Gutiérreza,b, Pablo Avanzasb,c,d,
Corresponding author
avanzas@secardiologia.es

Corresponding author:
, Pablo Sollaa,b, Rocío Díazb,c, Juan José Solanoa,b,d, César Morísb,c,d
a Área de Gestión Clínica de Geriatría, Hospital Monte Naranco, Oviedo, Asturias, Spain
b Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Asturias, Spain
c Área de Gestión Clínica del Corazón, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
d Departamento de Medicina, Universidad de Oviedo, Oviedo, Asturias, Spain
Related content
Magali González-Colaço Harmand, Miguel Leiva Gordillo, Myriel López Tatis, Francisco Ignacio Bosa Ojeda
This item has received
Article information
Full Text
Bibliography
Download PDF
Statistics
Figures (1)
Tables (1)
Table 1. Baseline characteristics of the study population and new problems detected
Full Text
To the Editor,

Aortic stenosis (AS) is the most common valve disease in the elderly. Older patients may have suboptimal results with surgical or transcatheter (TAVI) aortic valve replacement,1 with higher rates of morbidity, mortality, and readmission, as well as worse quality of life, all of which stem from the particular characteristics of the disease in the elderly.2 Following the PARTER3 trials, TAVI became established as the treatment of choice in elderly patients with AS. Comprehensive geriatric assessment improves health outcomes by allowing steps to be taken to deal with potentially modifiable situations of frailty.4 The aims of this study were: a) to study the clinical, functional, mental, and social characteristics of elderly patients with symptomatic severe AS who are to undergo valve replacement, and b) to analyze the possible presence of undiagnosed diseases, situations of frailty, functional dependence, and cognitive decline.

This was a longitudinal, prospective, observational study, which included consecutive patients older than 75 years old with symptomatic severe AS referred for TAVI or surgical aortic valve replacement and assessed by the multidisciplinary Heart Team, between 1 May 2018 and 30 April 2019 (figure 1).

Figure 1.

Patients included in the program. AS, aortic stenosis; SAVR, surgical aortic valve replacement; TAVI, transcatheter aortic valve implantation.

(0.17MB).

The characteristics of the study population are given in table 1. A total of 79.8% of the patients were aged 80 years or older. The most prevalent comorbidities were hypertension, dyslipidemia, and anemia, with a mean score on the Short-Form Charlson Comorbidity Index of 2.47±2. We found a mean 9.01±3.11 previously-diagnosed medical conditions, 2.01±1.89 previous operations and a mean 6.99±3.4 long-term repeat-prescription medications. Mean body mass index was 29.05±5.53 and mean Mini Nutritional Assessment Short Form score was 11.33±1.69 (within the range for normal/at risk of malnutrition). Functional assessment detected a high level of independence for activities of daily living (mean scores on Barthel index, 93.04±11.64, and on the Lawton scale, 5.79±2.06). On frailty assessment, the mean Essential Frailty Toolset score was 1.28±1.08 (within the robust range) and the mean Short Physical Performance Battery score was 8.67±2.47 (in the prefrail range). On mental assessment, the mean Mini-Mental State Examination score was 26.65±3.39, mean score on Reisberg’ Global Deterioration Scale was 1.38±0.77, and mean score on Yesavage's Geriatric Depression Scale was 3.08±2.68 (corresponding to no cognitive or affective impairment). Regarding social situation, the mean score on the Gijón assessment scale was 6.35±1.87, with 100% of patients obtaining results within the “no social risk” range.

Table 1.

Baseline characteristics of the study population and new problems detected

General characteristics  (n=120) 
Age, y  83.45±4.55 
Female  65 
Previous ACS  21.7 
Previous revascularization surgery  20.3 
Atrial fibrillation  26.7 
Previous HF  19.2 
EuroSCORE II  3.95±3.3 
Cardiovascular risk factors
HTN  73.3 
Dyslipidemia  42.5 
Diabetes mellitus  26.7 
Comorbidities
Anemia  33.3 
Depression  20.8 
Thyroid disease  19.2 
Chronic kidney disease  17.5 
COPD  15.8 
Peripheral arterial disease  15 
Stroke  8.3 
Mild cognitive decline/dementia  3.3 
Functional class
NYHA I  7.5 
NYHA II  60.7 
NYHA III  30.8 
NYHA IV  0.9 
Echocardiographic parameters
Aortic valve area, cm2  0.67±0.19 
Mean valve gradient, mmHg  48.02±14.45 
Maximum valve gradient, mmHg  76.5±21.63 
Pulmonary hypertension  20.8 
LVEF   
Preserved  79.8 
Reduced  20.2 
Blood tests
Hemoglobin, g/dL  12.72±1.92 
Albumin, g/dL  4.31±0.41 
eGFR, mL/min/1.73 m2  58.53±18.81 
HbA1C(% total)  6.33±0.99 
Folate, μg/dL  7.33±4.66 
Vitamin B12, pg/mL  451.44±243.05 
TSH, mU/L  2.31±1.78 
25OH-D3, ng/mL  18.53±12.32 
Nutritional status
BMI   
Normal  20.8 
Overweight  39.2 
Obese  29.2 
Severely obese  7.5 
Morbidly obese  3.3 
MNA   
Normal  56.7 
At risk of malnutrition  40.8 
Malnutrition  2.5 
Frailty and functional assessment
Barthel index   
Independent  73.3 
Mildly dependent  25.9 
Moderately dependent 
Severely dependent  0.8 
Completely dependent 
Lawton index (stratified by sex)   
Independent  54.6 
Mildly dependent  22.7 
Moderately dependent  16.0 
Severely dependent  4.2 
Completely dependent  2.5 
EFT   
Robust  87.4 
Frail  12.6 
SPPB   
Robust  41.3 
Prefrail  41.3 
Frail  17.4 
Mental assessment
MMSE   
Normal  70.3 
Probable cognitive impairment  14.4 
Impairment  13.5 
Dementia  0.9 
Not applicable  0.9 
Reisberg GDS   
No decline  74.2 
Very mild decline  19.2 
Mild decline  4.2 
Moderate decline  1.7 
Severe decline  0.8 
Yesavage depression scale   
Normal  75 
Mild  20.8 
Moderate  4.2 
Severe 
New problems detected
Clinical   
Vitamin D deficiency  96.7 
Probable CKD  42.9 
Anemia  27.5 
Thyroid disease  7.2 
Vitamin B12 deficiency  6.7 
DM  5.7 
Urological problems  4.2 
Iron deficiency without anemia  3.3 
Folate deficiency  3.3 
COPD  3.0 
Prescribing   
Polypharmacy  63.3 
Inappropriate prescribing  45.8 
Nutritional   
Underweight  77.5 
At risk of malnutrition  40.8 
Malnutrition  7.5 
Functional   
Prefrailty  37.5 
Frailty  15.8 
Dependent for IADL  45.4 
Dependent for BADL  26.6 
Mental and emotional   
Mild cognitive decline or dementia  14.7 
Depression  1.1 

25OH-D3: vitamin D; ACS, acute coronary syndrome; BADL, basic activities of daily living; BMI, body mass index; CKD, chronic kidney disease; COPD, chronic obstructive pulmonary disease; DM, diabetes mellitus; EFT, Essential Frailty Toolset; eGFR, estimated glomerular filtration rate; HbA1C, glycated hemoglobin; HF, heart failure; HTN, hypertension; IADL, instrumental activities of daily living; LVEF, left ventricular ejection fraction; MMSE, Mini-Mental State Examination; MNA, Mini Nutritional Assessment Short Form; NYHA, New York Heart Association; Reisberg GDS, Reisberg's global deterioration scale; SPPB, Short Physical Performance Battery; TSH, thyroid-stimulating hormone.

Values are expressed as n (%) or mean±standard deviation.

Following comprehensive geriatric assessment, there was a mean 6±2.36 new diagnoses per patient (720 in total). Undiagnosed vitamin D deficiency with no known history was identified in 96.7%, and severe deficiency in 17.4%. Polypharmacy was diagnosed in 63.3% of patients; benzodiazepine prescription was the most common inappropriate prescription (37.5%). Suboptimal prescription was identified in 4.2% of patients and treatment nonadherence in 1.7%. Malnutrition or risk of malnutrition was present in 43.3% of the patients and hypoalbuminemia in 5.8%. Rates of frailty varied between 12.6% and 17.4% depending on the screening tool used. Some degree of functional dependence for basic activities of daily living was present in 26.7%, while functional dependence for instrumental activities of daily living was found in 45.4%. Previously undiagnosed mild cognitive decline or dementia was present in 14.7%; depression was found in 1.1% of patients with no previous history, and adjustment disorder or anxiety was identified in 10.8%.

The main finding in our study was that elderly patients with severe AS referred for valve replacement had similar levels of comorbidity, polypharmacy, and malnutrition to those identified in other populations such as in the CGA-TAVI multicenter registry5 or the FRAILTY-AVR Study,6 although the scores from the tools that specifically evaluate frailty indicated that they were slightly more robust. They also had undiagnosed conditions including vitamin deficiencies, chronic kidney disease, anemia, diabetes, thyroid disease, nutritional problems, and mild cognitive decline. We also found situations of frailty and functional dependency amenable to intervention and, likely, reversal. The detection of all these problems through a comprehensive geriatric assessment is essential, as it lays the foundations for a future analysis to determine whether a multicomponent low-intensity physical exercise program prior to valve replacement could help improve these patients’ care process and health outcomes. Our study has 2 main limitations: it was a single-center study and it involved a selected population (patients referred to the multidisciplinary Heart Team). As a strength, our study is the first to routinely perform, in all patients, a comprehensive geriatric assessment including nutritional, functional, mental, and frailty assessment, with a specific focus on detecting undiagnosed problems.

References
[1]
H. Baumgartner, V. Falk, J.J. Bax, et al.
ESC Scientific Document Group 2017 ESC/EACTS Guidelines for the management of valvular heart disease. The Task Force for the Management of Valvular Heart Disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS).
Eur Heart J., 38 (2017), pp. 2739-2791
[2]
G. Pulignano, M.M. Gulizia, S. Baldasseroni, et al.
ANMCO/SIC/SICI-GISE/SICCH Executive Summary of Consensus Document on Risk Stratification in elderly patients with aortic stenosis before surgery or transcatheter aortic valve replacement.
Eur Heart J Suppl., 19 (2017), pp. D354-D369
[3]
M.J. Mack, M.B. Leon, C.R. Smith, et al.
5-year outcomes of transcatheter aortic valve replacement or surgical aortic valve replacement for high surgical risk patients with aortic stenosis (PARTNER 1): a randomised controlled trial.
Lancet., 385 (2015), pp. 2477-2484
[4]
A. Ungar, A. Schoenenberger, S. Maggi, et al.
The value of comprehensive geriatric assessment in elderly patients with severe aortic stenosis — A position statement of the European Union Geriatric Medicine Society (EUGMS).
Eur Geriatr Med., 6 (2015), pp. 271-273
[5]
A. Ungar, G. Mannarino, N. van der Velde, et al.
Comprehensive geriatric assessment in patients undergoing transcatheter aortic valve implantation — Results from the CGA-TAVI multicentre registry.
BMC Cardiovasc Disord., 18 (2018), pp. 1-16
[6]
J. Afilalo, S. Lauck, D.H. Kim, et al.
Frailty in older adults undergoing aortic valve replacement: the FRAILTY-AVR Study.
J Am Coll Cardiol., 70 (2017), pp. 689-700
Copyright © 2019. Sociedad Española de Cardiología
Idiomas
Revista Española de Cardiología (English Edition)

Subscribe to our newsletter

View newsletter history
Article options
Tools
es en

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?