Mary A. Dolansky

Women's and men's exercise adherence after a cardiac event.

The purpose of this secondary analysis was to determine whether age affects womens and mens exercise adherence after a cardiac event. In a convenience sample of 248 adults ages 38 to 86 who had a cardiac event, exercise adherence (three exercise sessions per week) was compared between men and women in three age groups (younger than 60, 61 to 70, and older than 70). Exercise patterns were recorded by heart rate monitors worn during exercise. No differences were found in adherence between the age groups for women; older men were nonadherent sooner than younger men when controlling for fitness level, pain, comorbidity, self-efficacy, depressed mood, and social support. Exercise adherence after a cardiac event was higher for younger men compared with older men. For all age groups, less than 37% of the total sample adhered to a three-times-per-week exercise regimen after 1 year, suggesting that interventions to maintain exercise adherence are needed.

Effects of Cardiac Rehabilitation on the Recovery Outcomes of Older Adults After Coronary Artery Bypass Surgery

PURPOSE This study aimed to examine differences in lower extremity function as well as perception of physical and mental function between adults 70 years of age or older who participated in a phase 2 cardiac rehabilitation program (CRP) (n = 32) and those who did not participate in a CRP (n = 33) after coronary artery bypass surgery (CABS). METHODS In this two-group longitudinal comparative study, recovery outcomes measured at baseline (6 weeks) and 6 months after CABS were compared between older adults who participated and those who did not participate in a CRP. RESULTS In study groups that were equivalent before the CRP, analysis of covariance (controlling for baseline scores) showed that 6 months after hospital discharge, those who participated in a CRP had greater lower extremity strength (F = 3.9; P =.04), greater ankle range of motion (F = 4.2; P =.02), better dynamic balance (F = 8.2; P =.003), better static balance (F = 3.3; P =.04), better gait (F = 4.7; P =.02), and perceptions of better physical function (F = 14.8; P =.00). The results remained the same when control was used for the effects of social support, self-efficacy, depression, comorbidity, cardiac functional status, and gender for all the variables except static balance. No difference related to perception of mental function was found between the study groups (F =.10; P =. 74). CONCLUSIONS Participation in a CRP by older individuals improves lower extremity function (an important dimension in preventing disability) and perception of physical function. Cardiac rehabilitation programs can be used to optimize the recovery outcomes of older individuals after CABS.

Heart failure management in skilled nursing facilities: A scientific statement from the American Heart Association and the Heart Failure Society of America

655 Heart failure (HF) is a complex syndrome in which structural or functional cardiac abnormalities impair the filling of ventricles or left ventricular ejection of blood. HF disproportionately occurs in those ≥65 years of age. Among the estimated 1.5 to 2 million residents in skilled nursing facilities (SNFs) in the United States, cardiovascular disease is the largest diagnostic category, and HF is common. Despite the high prevalence of HF in SNF residents, none of the large randomized clinical trials of HF therapy included SNF residents, and very few included patients >80 years of age with complex comorbidities. Several issues make it important to address HF care in SNFs. The healthcare environment and characteristics of SNF residents are distinct from those of community-dwelling adults. Comorbid illness unrelated to HF (eg, dementia, hip fracture) increases with age >75 years, and these conditions may complicate both the initial HF diagnosis and ongoing management. Morbidity and mortality rates are significantly increased for hospitalized older adults with HF discharged to SNFs compared with those discharged to other sites. Transitions between hospitals and SNFs may be problematic. SNF 30-day rehospitalization rates for HF range from 27% to 43%, and long-term care residents sent to the emergency department are at increased risk for hospital admission and death. The purpose of this scientific statement is to provide guidance for management of HF in SNFs to improve patientcentered outcomes and reduce hospitalizations. This statement addresses unique issues of SNF care and adapts HF guidelines and other recommendations to this setting.

Post-acute care services received by older adults following a cardiac event: a population-based analysis.

Background:Post-acute care (PAC) is available for older adults who need additional services after hospitalization for acute cardiac events. With the aging population and an increase in the prevalence of cardiac disease, it is important to determine current PAC use for cardiac patients to assist health care workers to meet the needs of older cardiac patients. The purpose of this study was to determine the current PAC use and factors associated with PAC use for older adults following hospitalization for a cardiac event that includes coronary artery bypass graft and valve surgeries, myocardial infarction (MI), percutaneous coronary intervention (PCI), and heart failure (HF). Methods and Results:A cross-sectional design and the 2003 Medicare part A database were used for this study. The sample (n = 1493521) consisted of patients 65 years and older discharged after their first cardiac event. Multinomial logistic regression was used to examine factors associated with PAC use. Overall, PAC use was 55% for cardiac valve surgery, 50% for MI, 45% for HF, 44% for coronary artery bypass graft, and 5% for PCI. Medical patients use more skilled nursing facility care, and surgical patients use more home health care. Only 0.1% to 3.4% of the cardiac patients use intermediate rehabilitation facilities. Compared with those who do not use PAC, those who use home health care and skilled nursing facility care are older and female, have a longer hospital length of stay, and have more comorbidity. Asians, Hispanics, and Native Americans were less likely to use PAC after hospitalization for an MI or HF. Conclusions:The current rate of PAC use indicates that almost half of nondisabled Medicare patients discharged from the hospital following a cardiac event use one of these services. Health care professionals can increase PAC use for Asians, Hispanics, and Native Americans by including culturally targeted communication. Optimizing recovery for cardiac patients who use PAC may require focused cardiac rehabilitation strategies.

The Bridge Project: Improving Heart Failure Care in Skilled Nursing Facilities

INTRODUCTION Rehospitalization rates and transitions of care for patients with heart failure (HF) continue to be of prominent importance for hospital systems around the United States. Skilled nursing facilities (SNF) are pivotal sites for transition especially for older adults. The purpose of this study was to evaluate in SNF both the (1) current state of HF management (HF admissions, protocols, and staff knowledge) and (2) the acceptability and effect of a HF staff educational program. METHODS Four SNF participated in the project, 2 the first year and 2 the second year. SNF were surveyed by discipline as to HF disease management techniques. Staff were evaluated on HF knowledge and confidence in pre- and post-HF disease management training. RESULTS All-cause rehospitalization rates ranged from 18% to 43% in the 2 SNF evaluated. Overall, there was a lack of identification and tracking of HF patients in all the SNF. There were no HF-specific disease management protocols at any SNF and staff had limited knowledge of HF care. Staff pre and post test scores indicated an improvement in both staff knowledge and confidence in HF management after receiving training. CONCLUSION The lack of identification and tracking of patients with HF limits SNF ability to care for patients with HF. HF education for staff is likely important to effective HF management in the SNF.

The MoCA and MMSE as screeners for cognitive impairment in a heart failure population: A study with comprehensive neuropsychological testing

OBJECTIVE To examine the ability of the Mini Mental Status Examination (MMSE) and Montreal Cognitive Assessment (MoCA) to detect cognitive impairment in persons with heart failure (HF). BACKGROUND Although the MMSE and MoCA are commonly used screeners in HF, no research team has validated their performance against neuropsychological testing. METHODS Participants were 106 patients with HF (49.1% male, 68.13 ± 9.82 years) who completed the MoCA, MMSE, and a full neuropsychological battery. Sensitivity and specificity were examined. Discriminant function analyses tested whether the screeners correctly detected cognitive impairment. RESULTS A MoCA score <25 and MMSE score of <28 yielded optimal sensitivity/specificity (.64/.66 and .70/.66, respectively). The MoCA correctly classified 65% of patients, Wilks lambda = .91, χ(2)(1) = 9.89, p < .01, and the MMSE correctly classified 68%, Wilks lambda = .87, χ(2)(1) = 14.26, p < .001. CONCLUSIONS In HF, both the MoCA and MMSE are useful in identifying the majority of patients with and without cognitive impairment. Both tests misclassified approximately one-third of patients, so continued monitoring and evaluation of patients is needed in conjunction with screening.

Evaluation of the recommended core components of cardiac rehabilitation practice: an opportunity for quality improvement.

PURPOSE: Guidelines have been established that describe recommended core components for cardiac rehabilitation (CR) programs; yet, there are no national efforts to monitor the integration of the guidelines. The purpose of this research was to describe incorporation of core components in CR programs. METHODS: This was a cross-sectional study using the Ohio Phase II Cardiac Rehabilitation Survey. Descriptive analyses were stratified on American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) certification, case management, and staff mix. RESULTS: Sixty-six percent (n = 94) of programs responded, 39% (n = 37) were AACVPR certified, 40% (n = 38) used case management, and 73% (n = 75) staffed an exercise physiologist. Notable findings included that only 44% of programs obtained/performed a 12-lead electrocardiogram and 36% screened for depression. AACVPR-certified programs compared with uncertified programs were more likely to manage overweight/obesity (100% vs 84% instruct on weight control, respectively, P = .02) and perform health assessments upon admission (89% vs 70% respectively, P = .04). Programs using case management when compared with programs that did not use case management were more likely to administer a health survey (92% vs 65%, respectively, P = .003) and risk stratify (100% vs 84%, respectively, P = .02). Programs with an exercise physiologist were more likely to administer/obtain a stress test when compared with those without an exercise physiologist (78% vs 56%, respectively, P = .04). CONCLUSIONS: There was a lack of consistency in the incorporation of core component guidelines; certification, case management, and staff mix offered little improvement. This study provides direction for statewide quality improvement initiatives to improve care delivered in CR programs.

Prioritizing Functional Capacity as a Principal End Point for Therapies Oriented to Older Adults With Cardiovascular Disease: A Scientific Statement for Healthcare Professionals From the American Heart Association

Adults are living longer, and cardiovascular disease is endemic in the growing population of older adults who are surviving into old age. Functional capacity is a key metric in this population, both for the perspective it provides on aggregate health and as a vital goal of care. Whereas cardiorespiratory function has long been applied by cardiologists as a measure of function that depended primarily on cardiac physiology, multiple other factors also contribute, usually with increasing bearing as age advances. Comorbidity, inflammation, mitochondrial metabolism, cognition, balance, and sleep are among the constellation of factors that bear on cardiorespiratory function and that become intricately entwined with cardiovascular health in old age. This statement reviews the essential physiology underlying functional capacity on systemic, organ, and cellular levels, as well as critical clinical skills to measure multiple realms of function (eg, aerobic, strength, balance, and even cognition) that are particularly relevant for older patients. Clinical therapeutic perspectives and patient perspectives are enumerated to clarify challenges and opportunities across the caregiving spectrum, including patients who are hospitalized, those managed in routine office settings, and those in skilled nursing facilities. Overall, this scientific statement provides practical recommendations and vital conceptual insights.

Randomized Controlled Feasibility Trial of Two Telemedicine Medication Reminder Systems for Older Adults with Heart Failure

We conducted a feasibility study of a telehealth intervention (an electronic pill box) and an m-health intervention (an app on a smartphone) for improving medication adherence in older adults with heart failure. A secondary aim was to compare patient acceptance of the devices. The participants were 60 adults with HF (65% male). Their average age was 69 years and 83% were Caucasian. Patients were randomized using a 2 × 2 design to one of four groups: pillbox silent, pillbox reminding, smartphone silent, smartphone reminding. We examined adherence to 4 medications over 28 days. The overall adherence rate was 78% (SD 35). People with the telehealth device adhered 80% of the time and people with the smartphone adhered 76% of the time. Those who received reminders adhered 79% of the time, and those with passive medication reminder devices adhered 78% of the time, i.e. reminding did not improve adherence. Patients preferred the m-health approach. Future interventions may need to address other contributors to poor adherence such as motivation.

Heart Failure Management in Skilled Nursing Facilities A Scientific Statement From the American Heart Association and the Heart Failure Society of America

Heart failure (HF) is a complex syndrome in which structural or functional cardiac abnormalities impair the filling of ventricles or left ventricular ejection of blood. HF disproportionately occurs in those ≥65 years of age.1 Among the estimated 1.5 to 2 million residents in skilled nursing facilities (SNFs) in the United States, cardiovascular disease is the largest diagnostic category, and HF is common.2,3 Despite the high prevalence of HF in SNF residents, none of the large randomized clinical trials of HF therapy included SNF residents, and very few included patients >80 years of age with complex comorbidities. Several issues make it important to address HF care in SNFs. The healthcare environment and characteristics of SNF residents are distinct from those of community-dwelling adults. Comorbid illness unrelated to HF (eg, dementia, hip fracture) increases with age >75 years, and these conditions may complicate both the initial HF diagnosis and ongoing management.4–6 Morbidity and mortality rates are significantly increased for hospitalized older adults with HF discharged to SNFs compared with those discharged to other sites.7 Transitions between hospitals and SNFs may be problematic.8 SNF 30-day rehospitalization rates for HF range from 27% to 43%,7,9,10 and long-term care residents sent to the emergency department are at increased risk for hospital admission and death.11 The purpose of this scientific statement is to provide guidance for management of HF in SNFs to improve patient-centered outcomes and reduce hospitalizations. This statement addresses unique issues of SNF care and adapts HF guidelines and other recommendations to this setting. This scientific statement on HF management in SNFs was developed by a writing group of experts representing nursing, medicine (cardiology, geriatrics, nursing home physicians, and palliative medicine), pharmacology, physical therapy, dietary clinical management, research, and …