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Objective: To evaluate the effects of the angiotensin converting enzyme inhibitor perindopril on six minute walking distance and quality of life in very old patients with left ventricular systolic dysfunction.Design: Prospective, double blind placebo controlled trial.Setting: Medicine for the elderly day hospital.Patients: 66 patients (average age 81) with left ventricular systolic dysfunction identified by echocardiography.Interventions: 10 weeks of treatment with titrated doses of perindopril or placebo.Main Outcome Measures: Six minute walking distance 10 weeks following treatment, quality of life measurements including the Minnesota living with heart failure questionnaire and the 36 item short form health survey.Results: In patients with left ventricular systolic dysfunction, six minute walking distance was significantly increased in the treatment group (37.1 m) compared with the placebo group (-0.3 m, p < 0.001). The medication was well tolerated and there were no significant adverse events.Conclusions: Six minute walking distance is improved considerably by treatment with perindopril in older patients with heart failure caused by left ventricular systolic dysfunction. [ABSTRACT FROM AUTHOR]

A recent increase in the incidence of diabetes and pre-diabetes is causing many employers to spend more of their healthcare benefit budgets to manage the conditions. A self-insured university in the USA has implemented an interprofessional diabetes mellitus risk reduction program using its own employee faculty and staff experts to help fellow employees manage their diabetes and pre-diabetes. The interprofessional team consists of five pharmacists, a dietitian, an exercise physiologist, a health educator and a licensed mental health practitioner. In addition, the participant's physician serves as a consultant to the program, as does a human resources healthcare benefits specialist and a wellness coordinator. The volunteer program takes place at the worksite during regular business hours and is free of charge to the employees. The faculty and staff delivering the program justify the cost of their time through an interprofessional educational model that the program will soon provide to university students.

An important component to optimal health is quality of life (QOL). Several healthy lifestyle behaviors have independently shown to improve QOL. The simultaneous implementation of multiple lifestyle behaviors is thought to be difficult, and the current literature lacks the assessment of multiple lifestyle behaviors simultaneously with respect to the effect on QOL. This current pilot study sought to develop a method to quantify multiple lifestyle behaviors into a single index value. This value was then measured with QOL for a possible correlation. The results showed that it is possible to convert multiple raw healthy lifestyle data points into a composite value and that an improvement in this value correlates to an improved QOL. After 12 months of participation in a cardiovascular risk reduction program, study participants (N = 35) demonstrated a 37.4% (P < 0.001) improvement in the composite lifestyle index (CLI). The improved CLI demonstrated a correlation with a statistically significant improvement in how participants rated their overall health in 12 months (r = 0.701, P < 0.001) as well as the number of self-reported unhealthy days per month in 12 months (r = -0.480, P = 0.004).

Objectives: To ascertain trends in function and mortality after admission to a medicine for the elderly rehabilitation unit, and to analyze factors associated with these outcomes., Design: Retrospective cohort analysis of routinely collected clinical data during the period from January 1, 1999, to December 31, 2008., Setting: Hospital-based medicine for the elderly rehabilitation unit., Participants: Patients (N=4449) admitted for rehabilitation after medical and surgical illness, stroke, and fractured neck of the femur., Interventions: Not applicable., Main Outcome Measures: Analysis of routinely collected clinical data: admission and discharge Barthel scores; indices of cognitive impairment, mental illness, swallowing and feeding difficulties. Discharge diagnoses, place of discharge, date of death, and discharge medications were analyzed, along with length of stay. Regression analysis of factors associated with improvement in Barthel score, place of discharge, and postdischarge mortality., Results: Length of stay and admission Barthel scores were unchanged over the study period, but discharge Barthel scores improved from 13.5 (maximum score, 20) in 2002 to 14.8 in 2008 (P=.002 for trend). Discharge to home increased from 290 (61%) of 472 patients in 2001 to 290 (76%) of 382 patients in 2007 (P<.001 for trend). Age, admission Barthel score, cognitive impairment, problems with understanding, and problems with expression were independent predictors of the change in Barthel score between admission and discharge. The adjusted hazard ratio for postdischarge mortality in 2007 to 2008 compared with 1999 to 2000 was .76 (95% confidence interval, .63-.93)., Conclusions: Functional and mortality outcomes improved over a 10-year period in this rehabilitation unit, despite similar Barthel scores on admission and equivalent lengths of stay., (Copyright © 2011 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: To compare the prevalence of use of potentially inappropriate medicines (PIMs) between older patients living in their own homes versus those living in nursing or residential homes, and to test the association between exposure to PIMs and mortality., Design: Cohort study stratified by place of residence., Setting: Tayside, Scotland., Participants: All people aged between 66 and 99 years who were resident or died in Tayside from 2005 to 2006., Main Outcome Measures: The exposure variable was PIM use as defined by Beers' Criteria. All cause mortality was the main outcome measure., Results: 70,299 people were enrolled in the cohort of whom 96% were exposed to any medicine and 31% received a PIM. Place of residence was not associated with overall risk of receiving PIMs, adjusted OR 0.94, 95% CI 0.87 to 1.01. Exposure to five of the PIMs (including long-acting benzodiazepines) was significantly higher in nursing homes whereas exposure to five other PIMs (including amitriptyline and NSAIDs) was significantly lower. Exposure to PIMs was similar (20-46%) across all 71 general practices in Tayside and was not associated with increased risk of mortality after adjustment for age, gender and polypharmacy (adjusted OR 0.98, 95% CI 0.92 to 1.05)., Conclusions: The authors question the validity of the full list of PIMs as an indicator of safety of medicines in older people because one-third of the population is exposed with little practice variation and no significant impact on mortality. Future studies should focus on management of a shorter list of genuinely high-risk medicines.

Access to echocardiography remains suboptimal for many older patients; hand-held echocardiography may improve access to this investigation. New methods of service provision may, however, not always result in appropriate use by clinicians. The aim of this study was to test whether the provision of hand-held echocardiography in a geriatric medicine service results in appropriate requests and changes in patient management. The methodology involved in this, was a prospective study of 100 patients referred for hand-held echocardiography in a geriatric medicine service. Information on reason for request, time from request to study, medical history, echocardiography history and medication were collected. Clinicians were asked how results had changed management 7-14 days after the investigation. The mean age of participating patients was 82.6 years. Echo requests were deemed appropriate in 93% of cases. Median time from request to echo was three days for inpatients and 14 days for outpatients. Fifty percent (50/100) of echos led to a change in cardiovascular management; a total of 75 separate changes in cardiovascular management resulted. Seventy-six percent of changes were deemed appropriate; 10% inappropriate and insufficient information was present for 14% of decisions. Provision of hand-held echocardiography allowed rapid investigation of patients for selected abnormalities. Requests were appropriate and appropriate changes to patient management occurred in most patients.

Chronic diseases like diabetes, hypertension, and dyslipidemia continue to be a significant burden on the US health care system. As a result, many healthcare providers are implementing strategies to prevent the incidence of heart disease and other chronic conditions. Among these strategies are proper drug therapy and lifestyle modifications. Behavior change is often the rate-limiting step in the prevention and maintenance of lifestyle modifications. The purpose of this paper is to describe a tool used to guide the progression and assess the effectiveness of a cardiovascular risk reduction program. The tool uses the Transtheoretical Model of Behavior Change to determine the readiness and confidence to change specific lifestyle behaviors pertinent to cardiovascular health. The tool aids the practitioner in developing a patient-centered plan to implement and maintain lifestyle changes and can be tailored to use in any situation requiring a behavior change on the part of the patient.

Background: Low 25-hydroxyvitamin D levels, commonly found in older patients with heart failure, may contribute to the chronic inflammation and skeletal myopathy that lead to poor exercise tolerance. We tested whether vitamin D supplementation of patients with heart failure and vitamin D insufficiency can improve physical function and quality of life., Methods and Results: In a randomized, parallel group, double-blind, placebo-controlled trial, patients with systolic heart failure aged >or=70 years with 25-hydroxyvitamin D levels <50 nmol/L (20 ng/mL) received 100,000 U of oral vitamin D2 or placebo at baseline and 10 weeks. Outcomes measured at baseline, 10 weeks, and 20 weeks were 6-minute walk distance, quality of life (Minnesota score), daily activity measured by accelerometry, Functional Limitations Profile, B-type natriuretic peptide, and tumor necrosis factor-alpha. Participants in the vitamin D group had an increase in their 25-hydroxyvitamin D levels compared with placebo at 10 weeks (22.9 versus 2.3 nmol/L [9.2 versus 0.9 ng/mL]; P<0.001) and maintained this increase at 20 weeks. The 6-minute walk did not improve in the treatment group relative to placebo. No significant benefit was seen on timed up and go testing, subjective measures of function, daily activity, or tumor necrosis factor. Quality of life worsened by a small, but significant amount in the treatment group relative to placebo. B-type natriuretic peptide decreased in the treatment group relative to placebo (-22 versus +78 pg/mL at 10 weeks; P=0.04)., Conclusions: Vitamin D supplementation did not improve functional capacity or quality of life in older patients with heart failure with vitamin D insufficiency. Clinical Trial Registration- www.controlled-trials.com. Identifier: ISRCTN51372896.

Chronic heart failure is a common problem in old age. Dyspnoea and fatigue are the most common symptoms and should alert the clinician to the likely diagnosis. When there is a clinical suspicion of heart failure, further assessment is required to confirm the aetiology. In older patients, heart failure with normal systolic function is frequently encountered. However, patients with left ventricular systolic dysfunction usually have a poorer prognosis, and most treatments have been evaluated in these patients. Useful investigations include the 12-lead electrocardiogram, chest radiology and echocardiography. A blood test for B-type natriuretic peptide is being increasingly used as a 'rule out' test for heart failure. There are several treatment options. Initially, patients should be treated with a diuretic and ACE inhibitor, provided there are no contraindications. beta-Blocker therapy is also first-line therapy once a patients' haemodynamic status has been stabilized. Additional treatments include spironolactone, angiotensin antagonists and digoxin. Patient factors and tolerability may limit the number of treatment options. Treatment regimes are most effective when delivered using a multidisciplinary approach.

Objectives: To determine the predictive power of B-type natriuretic peptide (BNP) regarding death in older, functionally impaired patients with multiple comorbidity., Design: Prospective cohort study., Setting: Specialist geriatric assessment clinic and day hospital., Participants: Two hundred ninety-nine older, functionally impaired patients, mean age 79 at enrollment., Measurements: Full clinical history and examination, baseline BNP, and echocardiography. Date and cause of death were ascertained from Scottish death records. Kaplan-Meier survival curves were constructed for quartiles of log (BNP), and the contribution of BNP to prediction of death was investigated., Results: The follow-up period ranged from 3.9 to 5.2 years (mean 4.4 years). BNP was a powerful independent predictor of all-cause and cardiovascular mortality. BNP was a more powerful predictor than blood pressure, diabetes mellitus, smoking, echocardiographic left ventricular hypertrophy, left ventricular systolic dysfunction, or age. BNP predicted death in those with and without a previous cardiovascular event at baseline., Conclusion: BNP has significant predictive power for death in older, functionally impaired patients.

Aim: To assess how well heart failure patients tolerate spironolactone in routine clinical practice., Design: Retrospective analysis of 226 patients attending a specialist heart failure clinic., Results: One hundred and thirty of 226 (57.5%) patients tried spironolactone at least once. Forty-four of 130 (33.8%) discontinued spironolactone due to side-effects after a mean of 11.1 months; 59/141 (41.8%) trials of spironolactone resulted in at least one side-effect; therapy was stopped in 30/141 (21.3%) trials due to raised potassium or creatinine. Significant risk factors for raised potassium/creatinine were age and baseline potassium level., Conclusions: Potentially serious side-effects are common despite appropriate use of spironolactone.

Background: Non-valvular atrial fibrillation (NVAF) is more common in elderly people, and is one of the most powerful independent risk factors predisposing to stroke. This risk increases with age. Despite evidence that full dose anticoagulation reduces this risk, and Scottish Intercollegiate Guidelines, warfarin is still being under prescribed, especially in elderly individuals., Objectives: To audit warfarin prescribing in elderly hospital patients with NVAF, and assess whether audit feedback and evidence based guidelines improved warfarin usage., Methods: Discharge summaries and medical notes were reviewed, and warfarin prescribing identified, for all patients with NVAF discharged from the Medicine for the Elderly Department between January 2001 and December 2002. This was done before (16 months) and after (7 months) audit results were presented at a departmental meeting, and evidence basedguidelines were produced., Results: Warfarin prescribing significantly increased from 38/121 (31.4%) prior to audit feedback and the introduction of guidelines to 30/55 (54.5%), Chi2-test, p < 0.01., Conclusions: Older patients with NVAF were under prescribed warfarin. Audit feedback and the introduction of evidence based guidelines significantly increased anticoagulation usage.

Objectives: To evaluate how well older heart failure patients tolerate beta-blockers in everyday clinical practice., Design: Retrospective casenote analysis., Setting: Specialist heart failure clinic in a large teaching hospital., Participants: 226 patients with a clinical diagnosis of heart failure and evidence of left ventricular systolic dysfunction., Measurements: Data on age, sex, comorbid illness, other medications, duration of beta-blocker therapy, side-effects and reasons for discontinuation., Results: Patients aged 75 years and over had a higher level of comorbid disease and worse New York Heart Association status. Despite this, 60.4% of those aged 75 or over had been tried on a beta-blocker (versus 69% of those aged <75), and of those tried, 80% of those aged 75 or over were still taking a beta-blocker at the time of survey (versus 86% of those aged <75). Forty-seven percent of those aged 75 or over had at least one side-effect recorded (versus 48% of those aged <75). Significant risk factors for failing a trial of beta-blocker therapy were worse New York Heart Association status and worse left ventricular function, but importantly not age., Conclusions: A high proportion of older heart failure patients tolerate beta-blockers. Side-effects and failure rates are comparable to younger patients. Left ventricular function and worse New York Heart Association class, rather than age, predict low tolerability of therapy. Further studies are warranted to evaluate whether frail patients with heart failure can improve their quality of life by taking beta-blockers.

Objectives: heart failure is primarily a disease of elderly people. Current guidelines suggest all patients with suspected heart failure should undergo objective assessment, usually by echocardiography. In the UK resources are limited and not all patients have access to echocardiography. The electrocardiogram is widely used as a pre-screening investigation. Recently the natriuretic peptides have been shown to correlate well with left ventricular function, and evidence is accumulating which suggests that B-type natriuretic peptide may have a role in detecting cardiovascular disease. Elderly patients attending day hospital often have non-specific cardiovascular symptoms. B-type natriuretic peptide measurement in parallel with conventional electrocardiogram, may offer a novel method of identifying those with significant cardiac disease, which may warrant treatment. This study assessed the role of B-type natriuretic peptide and electrocardiogram in the detection of cardiac disease in patients attending Day Hospital., Design: prospective cohort study of patients referred to Day Hospital with suspected cardiovascular disease., Methods: this study prospectively evaluated 299 consecutive patients attending day hospital over a period of 13 months. Patients underwent clinical assessment, electrocardiography, echocardiography and natriuretic peptide measurement. Objective evidence of cardiac disease was based on electrocardiogram and echocardiographic findings., Setting: Medicine for the Elderly Day Hospital, Royal Victoria Hospital, Dundee., Main Outcome Measures: sensitivity, specificity, positive and negative predictive values of screening tests for left ventricular systolic dysfunction. Receiver-Operating-Characteristic curves for ability of B-type natriuretic peptide to detect cardiac disease (including left ventricular systolic dysfunction, valvular disease, atrial fibrillation and left ventricular hypertrophy). Mean B-type natriuretic peptide levels with 'incremental' levels of cardiovascular disease., Results: 299 patients (mean age 79; 65% female) completed the assessment. Ten percent of patients had left ventricular systolic dysfunction but 50% had objective evidence of cardiac disease. B-type natriuretic peptide was significantly elevated in patients with left ventricular systolic dysfunction, atrial fibrillation, left ventricular hypertrophy and valvular disease. Both B-type natriuretic peptide and the electrocardiogram were sensitive in detecting left ventricular systolic dysfunction but lacked specificity. Combining B-type natriuretic peptide with the electrocardiogram improved detection of left ventricular systolic dysfunction. B-type natriuretic peptide levels increased progressively as the number of different cardiac abnormalities increased., Conclusions: B-type natriuretic peptide may be a useful marker for cardiac disease in patients attending Day Hospital. Half of the patients assessed had cardiac disease detected. Both the electrocardiogram and B-type natriuretic peptide were sensitive in the detection of left ventricular systolic dysfunction but lacked specificity. B-type natriuretic peptide was superior to the electrocardiogram in the detection of valvular disease. If used to pre-screen cardiovascular disease in Day Hospital patients, B-type natriuretic peptide and the electrocardiogram could reduce the need for echocardiography in some patients before implementing evidence-based treatments. B-type natriuretic peptide increases progressively as the number of different cardiac abnormalities increases and this may explain why B-type natriuretic peptide is of such prognostic value in older patients.

Background: Heart failure (HF) is difficult to diagnose and treat in older patients. Symptoms may be non-specific and the presence of co-morbidities and polypharmacy complicate treatment strategies. There are, however, few data to quantify the extent of these problems in the very elderly., Methods: A retrospective study of 116 patients (median age 86; range 65-98) with an established diagnosis of HF during their hospital admission., Main Outcome Measures: the accuracy of diagnosis of heart failure according to the European Society of Cardiology (ESC) definition. The aetiology and frequency of associated co-morbidities and the nature of drug treatment., Results: The specificities of clinical signs, chest X-rays and abnormal ECGs for heart failure (ESC definition) were 50%, 20% and 9%, respectively. Only 28% of patients were admitted for worsening symptoms which could be attributed to HF. None of the patients had HF as their only medical problem. Co-morbidities included chest disease (30%), incontinence (29%), cerebrovascular disease (26%), musculoskeletal problems (41%). Barthel (activities of daily living) score was < or = 16/20 in 35%. Mental state questionnaire (MSQ) score was < or =7/10 in 38%. Ninety percent were taking four or more different medications. Thirty-nine percent were on psychotropic drugs. On discharge, a total of 88% of patients returned home to live independently and 35% were monitored by regular day hospital attendance., Conclusion: Heart failure in frail elderly patients is often compounded by other major illnesses and polypharmacy which have a profound impact on their functional status. This has implications for the most effective targeting of evidence based treatment.

Objective: To assess the attitudes of consultant members of the British Geriatrics Society to elderly patients driving motor vehicles., Design: An anonymous postal survey assessing knowledge and attitudes to driving in elderly people. A standardized questionnaire was used and five case histories were offered for interpretation., Setting: The study was co-ordinated from a teaching hospital., Subjects: The 709 consultant members of the British Geriatrics Society. Four hundred and eighteen responses were obtained, which represents a 59% response rate., Results: 275 Respondents (68%) correctly realised that a person aged 70 had a duty to inform the Driving and Vehicle Licensing Authority (DVLA) about their eligibility to drive. The remainder did not. Most (315; 75%) believed that the overall responsibility for informing the DVLA was with the patient. If a patient was incapable of understanding advice on driving because of advanced dementia, 346 (83%) would breach patient confidentiality and inform the authority directly. Where a patient was fully capable of understanding medical advice but ignored it, 72% of geriatricians would have legitimately breached patient confidentiality and informed the DVLA. Most geriatricians (88%) saw their main role as one of providing advice on driving to patients and their families. Enforcing DVLA regulations was not seen as an appropriate function, unless the patient was a danger to themselves or other drivers., Conclusions: There is a wide variation in knowledge of driving regulations and attitudes to driving in elderly patients. Better education of geriatricians should improve awareness of when elderly drivers can safely continue to drive.

Objective: To assess the comparative contribution of clinical assessment, electrocardiography, and chest radiography to the diagnosis of left ventricular systolic dysfunction in patients admitted to a general medical ward with acute dyspnoea., Design: Prospective cross sectional study., Setting: Acute medical admissions ward of a teaching hospital., Subjects: 71 randomly selected patients admitted with acute dyspnoea., Main Outcome Measures: Sensitivity and specificity of each investigation and logistic regression analysis of each variable in identifying left ventricular systolic dysfunction., Results: Clinical assessment in this cohort of patients with severe dyspnoea was generally sensitive (sensitivity 81%). Patients were divided into three groups on the basis of clinical assessment. In the first group (37 patients) the diagnosis of systolic dysfunction was clear, in the second (22) it was in doubt, and in the third (12) it was unlikely. The sensitivity of clinical assessment in identifying left ventricular systolic dysfunction was 81% and the specificity was 47%. The specificity of diagnosis was improved by electrocardiography (69%) and chest radiography (92%). Logistic regression analysis showed that isolated pulmonary crepitations were a comparatively poor predictor of left ventricular systolic dysfunction chi 2 = 10.215, P = 0.0014) but that a full clinical examination had reasonable predictive value (chi 2 = 24.82, P < 0.00001). The combination of clinical assessment and chest radiography improved the accuracy of diagnosis (chi 2 = 28.08, P < 0.00001), as did the combination of clinical assessment and electrocardiography (chi 2 = 32.41, P < 0.00001)., Conclusion: Clinical assessment in patients admitted with acute dyspnoea is comparatively accurate. Patients with abnormal results on chest radiography, electrocardiography, and clinical examination have a high likelihood of having left ventricular systolic dysfunction. Echocardiography contributes little more to the diagnosis in these patients and may be more efficiently directed towards patients in whom the diagnosis is still in doubt after clinical assessment, chest radiography, and electrocardiography.

Objective: To assess the ability of a cohort of junior hospital doctors to interpret ECGs which have immediate clinical relevance and influence subsequent management of patients., Methods: 57 junior hospital doctors were interviewed and asked to complete a standard questionnaire which included eight ECGs for interpretation and a supplementary question relating to the administration of thrombolytic treatment. Each doctor was assessed over a 48 h period while they performed their daily clinical duties., Results: The major abnormality of anterior myocardial infarction was recognised by almost all doctors. There was difficulty in the interpretation of posterior myocardial infarction and second degree heart block. Most myocardial infarctions would have been given satisfactory thrombolysis, but there was a reluctance to use this treatment in patients with posterior myocardial infarction and left bundle brach block. A few patients without myocardial infarction would have received thrombolytic treatment., Conclusions: There is varying ability among junior hospital doctors in the interpretation of the emergency electrocardiogram. The results are of concern as poor interpretation of the ECG can result in inappropriate management. As a result of the findings of this study it is proposed to introduce more formal training in the interpretation of clinically relevant ECG abnormalities for junior hospital doctors.

There is little published data on the demand for echocardiography services in the U.K. This retrospective survey of echocardiography request forms and reports was performed to assess potential changes in echocardiography request patterns between 1988 and 1993. These years were chosen as they were likely to reflect changes in clinical practice as a result of trials involving Angiotensin Converting Enzyme (ACE) inhibitors. A total of 400 consecutive request forms and reports were analysed. There was a 2.46 fold increase in the total number of echocardiograms performed between 1988 and 1993 with a disproportionate 12.5 fold increase in the relative number of requests for assessments of left ventricular function. This large increase is likely to be a result of recent major clinical trials which show morbidity and mortality benefits when patients with left ventricular systolic dysfunction (including those who are asymptomatic) are treated with ACE inhibitors. Future planning of the echocardiographic services should include provision for the increasing numbers of patients requiring assessment of left ventricular function.