Ariela R. Orkaby

Impact of a Group Medical Visit Program on Latino Health-Related Quality of Life

CONTEXT Movement toward the Medical Home and group medical visits (GMV). OBJECTIVE To investigate the impact of a GMV program in an underserved Latino community. DESIGN Year-long observational community-based research pilot study evaluating the impact of twice weekly GMVs on quality of life, depression, and loneliness in Latinos with diabetes and other risk factors for heart disease. SETTING The Greater Lawrence Family Health Center in Lawrence, MA. Approved by the Tufts University review committee on human subjects as part of the CDC funded Latino Health 2010 initiative to evaluate and eliminate health disparities in minority populations. IRB # 5243. PATIENTS Fifty-seven Latino adults with diabetes and heart disease risk factors. INTERVENTIONS Participants had two intervention opportunities weekly, including the GMV. MAIN OUTCOME MEASURES Despite a high dropout rate, and baseline differences between groups, we found reduced depression and loneliness and improved quality-of-life indicators for participants with high attendance to GMVs during one year compared to those with low attendance. Mean depression scores in high attendees, measured by the Zung Depression Scale, improved from 46.83 to 38.85 (p < .001). Mean loneliness scores for high attendees, measured by the UCLA Loneliness Questionnaire, improved from 49.61 to 37.6 (P < .001). Quality-of-life indicators, measured by SF 36, showed statistically significant improvement in general health, vitality, bodily pain, mental health, and role-emotional (P < .05). High attendees also maintained constant weight with the average decreasing slightly during the year-long intervention. RESULTS Attending GMVs regularly was associated with improved health-related quality of life, decreased loneliness, decreased depression, and no weight gain. Despite a high dropout rate there were many participants mainly female. More research is needed.

Continued Use of Warfarin in Veterans with Atrial Fibrillation After Dementia Diagnosis

To determine the effectiveness of warfarin in older adults with dementia.

Metformin vs sulfonylurea use and risk of dementia in US veterans aged ≥65 years with diabetes

Objective: To determine whether metformin is associated with a lower incidence of dementia than sulfonylureas. Methods: This was a retrospective cohort study of US veterans ≥65 years of age with type 2 diabetes who were new users of metformin or a sulfonylurea and had no dementia. Follow-up began after 2 years of therapy. To account for confounding by indication, we developed a propensity score (PS) and used inverse probability of treatment weighting (IPTW) methods. Cox proportional hazards models estimated the hazard ratio (HR) of incident dementia. Results: We identified 17,200 new users of metformin and 11,440 new users of sulfonylureas. Mean age was 73.5 years and mean HbA1c was 6.8%. Over an average follow-up of 5 years, 4,906 cases of dementia were diagnosed. Due to effect modification by age, all analyses were conducted using a piecewise model for age. Crude hazard ratio [HR] for any dementia in metformin vs sulfonylurea users was 0.67 (95% confidence interval [CI] 0.61–0.73) and 0.78 (95% CI 0.72–0.83) for those <75 years of age and ≥75 years of age, respectively. After PS IPTW adjustment, results remained significant in veterans <75 years of age (HR 0.89; 95% CI 0.79–0.99), but not for those ≥75 years of age (HR 0.96; 95% CI 0.87–1.05). A lower risk of dementia was also seen in the subset of younger veterans who had HbA1C values ≥7% (HR 0.76; 95% CI 0.63–0.91), had good renal function (HR 0.86; 95% CI 0.76–0.97), and were white (HR 0.87; 95% CI 0.77–0.99). Conclusions: After accounting for confounding by indication, metformin was associated with a lower risk of subsequent dementia than sulfonylurea use in veterans <75 years of age. Further work is needed to identify which patients may benefit from metformin for the prevention of dementia.

Statins for Primary Prevention of Cardiovascular Events and Mortality in Older Men

We sought to determine whether statin use for primary prevention is associated with a lower risk of cardiovascular events or mortality in older men.

A Curious Case of Lactobacillus casei in a Prosthetic Joint:: Was It the Yogurt?

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Cross-Sectional Association of Frailty and Arterial Stiffness In Community-Dwelling Older Adults: The Framingham Heart Study.

BACKGROUND Frailty is a risk factor for cardiovascular disease (CVD). Underlying mechanisms to explain the connection between frailty and CVD are unclear. We sought to examine the association between frailty and arterial stiffness, a precursor of hypertension and CVD. METHODS We conducted a cross-sectional analysis of community-dwelling Framingham Heart Study Offspring and Omni participants ≥60 years of age examined in 2005-2008. Frailty was defined primarily according to the Fried physical phenotype definition, which identifies nonfrail, prefrail, and frail individuals. Arterial stiffness was assessed using carotid-femoral pulse wave velocity (CFPWV). Generalized linear regression was used to examine the association between frailty level and CFPWV (modeled as -1000/CFPWV in msec/m, then transformed back to the original scale, m/s), adjusted for age, sex, cohort, mean arterial pressure, heart rate, height, and smoking. RESULTS Of 2,171 participants (55% women, 91% white), 45% were prefrail and 7% were frail. Mean ages were 67, 70, and 73 years, and adjusted CFPWV least squares means were 10.0 (95% CI, 9.9-10.1), 10.3 (10.2-10.5), and 10.5 m/s (10.1-11.0); p = .0002 for nonfrail, prefrail, and frail groups, respectively. Results were similar using the Rockwood cumulative deficit model of frailty, and in a sensitivity analysis adjusting for prevalent coronary heart disease and diabetes. CONCLUSIONS Prefrailty and frailty were associated with higher arterial stiffness in a cohort of community-dwelling older adults. Arterial stiffness may help explain the relationship between frailty and CVD.

Comparison of two frailty indices in the physicians’ health study

BACKGROUND As the population ages it is important to identify frailty, a powerful predictor of morbidity and mortality, and often an important unmeasured confounder. We sought to develop a frailty index in the Physicians Health Study (PHS) and estimate the association with mortality. METHODS Prospective cohort study. Annual questionnaire assessed mood, function and health status. Two frailty scores were compared - cumulative deficit frailty index (PHS FI) and modified Study of Osteoporotic Fracture (mSOF) frailty score. Endpoints committee confirmed mortality. RESULTS 12,180 male physicians ≥60 years were analyzed. Mean(SD) follow-up was 10(3) years, 2168 deaths occurred. PHS FI identified 4412 (36%) physicians robust, 5305 (44%) pre-frail, and 2463 (20%) frail, while mSOF identified 7323 (61%) robust, 3505 (29%) pre-frail and 1215 (10%) frail. Age-standardized rate of death was lower among subjects identified as robust using the PHS FI, 11/1000 person-years (PY) (95% Confidence Interval (CI): 9.5-11.9) compared to 14/1000PY (95% CI: 13.5-15.4) using mSOF [P-difference <0.001]. In the prefrail group, death rates were 16/1000PY in PHS FI and 21/1000PY in mSOF, [P-difference <0.001]. There was no difference in age-adjusted mortality rates in the frail group according to each definition (35 vs 33/1000PY). Survival analysis showed an increased risk of mortality in each frailty category using either definition, (log-rank p<0.001). CONCLUSION The PHS FI outperformed mSOF in identifying risk of death particularly in robust and pre-frail categories. Similar indices can be created in existing datasets to identify frail individuals and where appropriate account for frailty, an often unmeasured confounder.

Prognostic Significance of Baseline Serum Sodium in Heart Failure With Preserved Ejection Fraction

Background The purpose of this study was to evaluate the relationship between serum sodium at the time of diagnosis and long term clinical outcomes in a large national cohort of patients with heart failure with preserved ejection fraction. Methods and Results We studied 25 440 patients with heart failure with preserved ejection fraction treated at Veterans Affairs medical centers across the United States between 2002 and 2012. Serum sodium at the time of heart failure diagnosis was analyzed as a continuous variable and in categories as follows: low (115.00–134.99 mmol/L), low‐normal (135.00–137.99 mmol/L), referent group (138.00–140.99 mmol/L), high normal (141.00–143.99 mmol/L), and high (144.00–160.00 mmol/L). Multivariable Cox regression and negative binomial regression were performed to estimate hazard ratios (95% confidence interval [CI]) and incidence density ratios (95% CI) for the associations of serum sodium with mortality and hospitalizations (heart failure and all‐cause), respectively. The average age of patients was 70.8 years, 96.2% were male, and 14% were black. Compared with the referent group, low, low‐normal, and high sodium values were associated with 36% (95% CI, 28%–44%), 6% (95% CI, 1%–12%), and 9% (95% CI, 1%–17%) higher risk of all‐cause mortality, respectively. Low and low‐normal serum sodium were associated with 48% (95% CI, 10%–100%) and 38% (95% CI, 8%–77%) higher risk of number of days of heart failure hospitalizations per year, and with 44% (95% CI, 32%–56%) and 18% (95% CI, 10%–27%) higher risk of number of days of all‐cause hospitalizations per year, respectively. Conclusions Both elevated and reduced serum sodium, including values currently considered within normal range, are associated with adverse outcomes in patients with heart failure with preserved ejection fraction.

Pravastatin for Primary Prevention in Older Adults: Restricted Mean Survival Time Analysis: Restricted Mean Survival Time for Pravastatin

To use restricted mean survival time, which summarizes treatment effects in terms of event‐free time over a fixed time period, to evaluate the benefit of pravastatin therapy for primary prevention of cardiovascular disease in older adults.

Physical activity and CVD in older adults: an expert’s perspective

ABSTRACT Introduction: The benefits of physical activity have long been recognized as powerful preventive opportunities for both prevention of cardiovascular disease and aging-related morbidity. However, physical activity remains under-prescribed and under-utilized. Areas covered: In this narrative review, the authors focus on physical activity as a modifiable lifestyle factor that can modify aging processes as well as cardiovascular pathophysiology that is often exacerbated by aging. Specific recommendations are provided for physical activity over the range of typical older individuals, spanning from those who are sedentary and frail to those who are active and robust. Expert commentary: Physical activity is a critically underused preventive strategy that can prevent cardiovascular disease and mitigate some of the physiological changes that occur with aging. Identifying activities that are accessible and enjoyable, while considering issues of safety, are key to developing an individualized exercise prescription for all older adults.