Date of Award

January 2018

Document Type

Thesis

Degree Name

Medical Doctor (MD)

Department

Medicine

First Advisor

Sarwat I. Chaudhry

Abstract

Older adults are at risk for functional decline after hospitalization for acute myocardial infarction (AMI). Our goal with this thesis is to explore two outcomes relevant to maintenance of physical function, falls and cardiac rehabilitation (CR) utilization in a cohort of adults over the age of 75 hospitalized with acute myocardial infarction. We aim to describe the risk of falls within six months of discharge and the rates of CR use, and to identify factors associated with these outcomes.

Our project uses data from the SILVER-AMI study, a prospectively designed cohort study which enrolled 3000 patients over the age of 75 hospitalized with acute myocardial infarction and followed them for six months after discharge. Extensive baseline data was collected on demographics, clinical and psychosocial factors, and geriatric impairments. Outcome data on falls was collected at six months via medical record adjudication and survey, and on CR use by survey.

557 (21.6%) of 2584 participants reported at least one fall within six months of discharge. Independent predictors after logistic regression analysis included: impaired functional mobility (OR 1.5 [1.07-2.11]), recent fall history (OR 2.97 [2.37- 3.74]), longer length of stay (OR 1.04 [1.02-1.07] per day, visual impairment (OR 1.33 [1.08-1.64]), and weak grip strength (OR 1.28 [1.02-1.60]).

192 (6.4%) of 3006 participants were found to have a medically serious fall within six months of discharge. Independent predictors of medically serious falls after logistic regression analysis included: impaired functional mobility (OR 1.85 [1.11-3.09]), recent fall history (OR 1.73 [1.23-2.42]), longer length of stay (OR 1.03 [1.01-1.06] per day, living alone (OR 1.37 [1.00-1.87, p = 0.048]), and impairment in the bathing ADL (OR 1.74 [1.06-2.86]).

943 (39.5%) of 2387 participants reported participating in CR within six months of discharge. Independent predictors of CR use after logistic regression analysis included: older age (OR 0.97 [0.95-0.99] per year), non-white race (OR 0.69 [0.50-0.97]), having less than 12 years of education (OR 0.71 [0.59-0.85]), receiving percutaneous (OR 2.07 [1.66-2.57]) or surgical (OR 4.70 [3.32-6.67]) revascularization, cognitive impairment (OR 0.58 [0.43-0.78]), and living alone (OR 0.77 [0.64-0.93]).

From these results, we conclude that falls and CR underutilization are important problems facing older adults after AMI. The comprehensive geriatric assessment performed in SILVER-AMI highlighted independent robust predictors of both functional outcomes. This indicates that there is a role for assessing geriatric impairments during an AMI hospitalization, as identifying patients at risk for poor functional outcomes can lead to steps toward improving their care. High fall risk could be a reason to avoid anticoagulant therapy. Identifying patients less likely to attend CR can allow development of interventions to close this gap in care.

Comments

This thesis is restricted to Yale network users only. It will be made publicly available on 06/27/2019

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