The Effect of Age on Functional and Mortality Outcomes After Acute Myocardial Infarction

Suzanne V. Arnold, MD, MHA, Karen P. Alexander, MD, Frederick A. Masoudi, MD, MSPH, P. Michael Ho, MD, PhD, Lan Xiao, PhD, and John A. Spertus, MD, MPH

OBJECTIVES: To determine the prevalence of post-myocardial infarction (MI) functional decline and to describe its association with chronological age in survivors of MI.

DESIGN: Prospective observational registry.

SETTING: Nineteen U.S. hospitals.

PARTICIPANTS: Two thousand four hundred eighty-one patients with acute MI.

MEASUREMENTS: Baseline and 1-year interviews identified subjects with functional decline, defined as a more than 5-point decline in Medical Outcomes Study 12-item Short Form Questionnaire (SF-12) Physical Component score or being "too ill" to provide a follow-up interview at 1 year. The relationship between age and functional decline was evaluated using logistic regression models adjusted for baseline SF-12 score, comorbidities, sociodemographics, and treatment characteristics. One-year mortality and a combined endpoint of death or decline were also compared across age.

RESULTS: Of 2,009 patients who survived to 1 year, 582 (29%) experienced a functional decline. In survivors, age was not associated with functional decline in unadjusted (odds ratio (OR)=0.95/decade, 95% confidence interval (CI)=0.88–1.03) or multivariable (OR=0.94, 95% CI=0.85–1.05) models. Although age was strongly associated with 1-year mortality (adjusted hazard ratio=1.42, 95% CI=1.21–1.66), there was no association between age and the combined endpoint of death or functional decline (adjusted OR=1.02, 95% CI=0.92–1.12).

CONCLUSION: More than one in four survivors of MI experiences a significant decline in physical function by 1 year. Although age is strongly associated with mortality, it had no association with functional decline. Because older patients have the same potential for favorable functional outcomes after an MI, age alone should not preclude aggressive treatment after an MI. J Am Geriatr Soc 2009;57(2):209-217.

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Effective Exercise for the Prevention of Falls: A Systematic Review and Meta-Analysis

Catherine Sherrington, PhD, Julie C. Whitney, MSc, Stephen R. Lord, DSc, Robert D. Herbert, PhD,
Robert G. Cumming, PhD, and Jacqueline C. T. Close, MD

OBJECTIVES: To determine the effects of exercise on falls prevention in older people and establish whether particular trial characteristics or components of exercise programs are associated with larger reductions in falls.

DESIGN: Systematic review with meta-analysis. Randomized controlled trials that compared fall rates in older people who undertook exercise programs with fall rates in those who did not exercise were included.

SETTING: Older people.

PARTICIPANTS: General community and residential care.

MEASUREMENTS: Fall rates.

RESULTS: The pooled estimate of the effect of exercise was that it reduced the rate of falling by 17% (44 trials with 9,603 participants, rate ratio (RR)=0.83, 95% confidence interval (CI)=0.75–0.91, P<.001, I2=62%). The greatest relative effects of exercise on fall rates (RR=0.58, 95% CI=0.48–0.69, 68% of between-study variability explained) were seen in programs that included a combination of a higher total dose of exercise (>50 hours over the trial period) and challenging balance exercises (exercises conducted while standing in which people aimed to stand with their feet closer together or on one leg, minimize use of their hands to assist, and practice controlled movements of the center of mass) and did not include a walking program.

CONCLUSION: Exercise can prevent falls in older people. Greater relative effects are seen in programs that include exercises that challenge balance, use a higher dose of exercise, and do not include a walking program. Service providers can use these findings to design and implement exercise programs for falls prevention. J Am Geriatr Soc 2008;56(12):2234-2243.

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BRIEF METHODOLOGICAL REPORTS

Agreement Between Nosologist and Cardiovascular Health Study Review of Deaths: Implications of Coding Differences

Diane G. Ives, MPH, Paulraj Samuel, MD, MPH, Bruce M. Psaty, MD, PhD, and Lewis H. Kuller, MD, DrPH

OBJECTIVES: To compare nosologist coding of underlying cause of death according to the death certificate with adjudicated cause of death for subjects aged 65 and older in the Cardiovascular Health Study (CHS).

DESIGN: Observational.

SETTING: Four communities: Forsyth County, North Carolina (Wake Forest University); Sacramento County, California (University of California at Davis); Washington County, Maryland (Johns Hopkins University); and Pittsburgh, Pennsylvania (University of Pittsburgh).

PARTICIPANTS: Men and women aged 65 and older participating in CHS, a longitudinal study of coronary heart disease and stroke, who died through June 2004.

MEASUREMENTS: The CHS centrally adjudicated underlying cause of death for 3,194 fatal events from June 1989 to June 2004 using medical records, death certificates, proxy interviews, and autopsies, and results were compared with underlying cause of death assigned by a trained nosologist based on death certificate only.

RESULTS: Comparison of 3,194 CHS versus nosologist underlying cause of death revealed moderate agreement except for cancer (kappa=0.91, 95% confidence interval (CI)=0.89–0.93). kappas varied according to category (coronary heart disease, kappa=0.61, 95% CI=0.58–0.64; stroke, kappa=0.59, 95% CI=0.54–0.64; chronic obstructive pulmonary disease, kappa=0.58, 95% CI=0.51–0.65; dementia, kappa=0.40, 95% CI=0.34–0.45; and pneumonia, kappa=0.35, 95% CI=0.29–0.42). Differences between CHS and nosologist coding of dementia were found especially in older ages in the sex and race categories. CHS attributed 340 (10.6%) deaths due to dementia, whereas nosologist coding attributed only 113 (3.5%) to dementia as the underlying cause.

CONCLUSION: Studies that use only death certificates to determine cause of death may result in misclassification and potential bias. Changing trends in cause-specific mortality in older individuals may be a function of classification process rather than incidence and case fatality. J Am Geriatr Soc 2009;57(1):133-139.

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Heart Disease Risk Factors in Midlife Predict Subclinical Coronary Atherosclerosis More than 25 Years Later in Survivors without Clinical Heart Disease: The Rancho Bernardo Study

Elizabeth Barrett-Connor, MD, Jacqueline Bergstrom, MS, C. Michael Wright, MD, and Caroline K. Kramer, MD

OBJECTIVES: To determine which of the classic modifiable coronary heart disease (CHD) risk factors, measured in midlife, are associated with subclinical coronary atherosclerosis in older age.

DESIGN: Prospective study.

SETTING: Community based.

PARTICIPANTS: Participants were 400 community-dwelling middle-aged adults who had no history of CHD at baseline (1972-1974), when CHD risk factors were measured, and who were still free of known CHD in 2000 to 2002.

MEASUREMENTS: Coronary artery plaque burden was assessed according to coronary artery calcium (CAC) score using computed tomography in 2000 to 2002.

RESULTS: Ordinal logistic regression analysis was used to compare baseline risk factors with severity of CAC. Mean age was 42 at baseline and 69 at the time of CAC assessment; 46.5% were male. In analyses adjusted for age, sex, and all other risk factors, one standard deviation increase in body mass index (odds ratio (OR)=1.24, 95% confidence interval (CI)=1.02–1.51; P=.03), cholesterol (OR=1.28, 95% CI=1.03–1.58; P=.020, pulse pressure (OR=1.24, 95% CI=1.03–1.50; P=.03), and log triglycerides (OR=1.22, 95% CI=0.99–1.50; P=.06) each independently predicted the presence and severity of coronary artery atherosclerosis.

CONCLUSION: Modifiable risk factors measured more than 25 years earlier influence plaque burden in elderly survivors without clinical heart disease. J Am Geriatr Soc 2009;57(6):1041-1044.