Multimorbidity in Older Adults With Cardiovascular Disease

Multimorbidity occurs in adults of all ages, but the number and complexity of comorbid conditions commonly increase with advancing age such that cardiovascular disease (CVD) in older adults typically occurs in a context of multimorbidity. Current clinical practice and research mainly target single disease-specific care that does not embrace the complexities imposed by concurrent conditions. In this paper, emerging concepts regarding CVD in combination with multimorbidity are reviewed, including recommendations for incorporating multimorbidity into clinical decision making, critical knowledge gaps, and research priorities to optimize care of complex older patients.     

Walking Cadence and Mortality Among Community-Dwelling Older Adults

BACKGROUND

Older adults are encouraged to walk ≥100 steps?minute^?1 for moderate-intensity physical activity (i.e., brisk walking). It is unknown if the ability to walk ≥100 steps?minute^?1 predicts mortality.

OBJECTIVE

To determine if the ability to walk ≥100 steps?minute^?1 predicts mortality among older adults.

DESIGN, SETTING, AND PATIENTS

A population-based cohort study among 5,000 older adults from the Third National Health and Nutrition Survey (NHANES III; 1988–1994). Vital status and cause of death were collected through December 31, 2006. Median follow-up was 13.4 years. Average participant age was 70.6 years.

MEASUREMENTS

Walking cadence (steps?minute^?1) was calculated using a timed 2.4-m walk. Walking cadence was dichotomized at 100 steps?minute^?1 (≥100 steps?minute^?1 versus <100 steps?minute^?1) to demarcate the lower threshold of absolutely defined moderate-intensity physical activity. Walking cadence was also analyzed as a continuous variable. Predicted survival was compared between walking cadence and gait speed. The primary outcome was all-cause mortality. Secondary outcomes included cardiovascular-specific and cancer-specific mortality and mortality from other causes.

RESULTS

Among 5,000 participants, 3,039 (61 %) walked ≥100 steps?minute^?1. During follow-up, 3,171 subjects died. In multivariable-adjusted analysis, ability to walk ≥100 steps?minute^?1 predicted a 21 % reduction in all-cause mortality (hazard ratio [HR], 0.79; 95 % confidence interval [95 % CI], 0.71–0.89, p?p??1 predicted reductions in cardiovascular-specific mortality (HR, 0.79 [0.67–0.92], p?=?0.002), cancer-specific mortality (HR, 0.76 [0.58–0.99], p?=?0.050), and mortality from other causes (HR, 0.82 [0.68–0.97], p?=?0.025). Predicted survival, adjusted for age and sex, was not different using walking cadence versus gait speed.

LIMITATIONS

Walking cadence was a cross-sectional measurement.

CONCLUSIONS

The ability to walk ≥100 steps?minute^?1 predicts a reduction in mortality among a sample of community-dwelling older adults.     

Start-Up Time and Walking Speed in Older Adults Under Loaded Conditions During Simulated Road Crossing

Background/Study Context: The safety of older pedestrians in road crossing has received considerable attention but previous studies measure gait characteristics only under unloaded conditions. The aim of this study was to investigate the start-up time and walking speed under loaded conditions that reflect daily activities of older adults in Singapore.

Methods: Thirty-two older adults (age (SD) = 69.4 (7.0) years) and 20 young controls (age (SD) = 23.1 (2.0) years) walked under four conditions: (1) unloaded, (2) pushing a stroller loaded with 10 kg, (3) pulling a shopping cart loaded with 15 kg, and (4) carrying two shopping bags each loaded with 2 kg. Start-up time was determined from video recordings and walking speed measured using timing gates. A mixed-model analysis of variance (ANOVA; age by walking condition) with repeated measures was applied.

Results: Start-up times were slower in the stroller and shopping cart conditions compared with the unloaded and shopping bags conditions. Loading reduced walking speed, with the shopping cart being the slowest, followed by the stroller and then the shopping bags. A significant interaction was found, with young controls reducing their speeds more substantially while handling the stroller/cart than older participants.

Conclusion: Loading caused a compromise in start-up time and walking speed. The start-up time was slower when pushing a stroller or pulling a shopping cart but remained unaffected by carrying shopping bags. Speed was reduced under all loaded conditions, with a greater effect in young than older participants when handling a stroller or shopping cart.     

Deprescribing in Older Adults With Cardiovascular Disease

Deprescribing, an integral component of a continuum of good prescribing practices, is the process of medication withdrawal or dose reduction to correct or prevent medication-related complications, improve outcomes, and reduce costs. Deprescribing is particularly applicable to the commonly encountered multimorbid older adult with cardiovascular disease and concomitant geriatric conditions such as polypharmacy, frailty, and cognitive dysfunction—a combination rarely addressed in current clinical practice guidelines. Triggers to deprescribe include present or expected adverse drug reactions, unnecessary polypharmacy, and the need to align medications with goals of care when life expectancy is reduced. Using a framework to deprescribe, this review addresses the rationale, evidence, and strategies for deprescribing cardiovascular and some noncardiovascular medications.