Expert consensus of the French Society of Geriatrics and Gerontology and the French Society of Cardiology on the management of atrial fibrillation in elderly people




Summary


Atrial fibrillation (AF) is a common and serious condition in the elderly. AF affects between 600,000 and one million patients in France, two-thirds of whom are aged above 75 years. AF is a predictive factor for mortality in the elderly and a major risk factor for stroke. Co-morbidities are frequent and worsen the prognosis. The management of AF in the elderly should involve a comprehensive geriatric assessment (CGA), which analyses both medical and psychosocial elements, enabling evaluation of the patient’s functional status and social situation and the identification of co-morbidities. The CGA enables the detection of “frailty” using screening tools assessing cognitive function, risk of falls, nutritional status, mood disorders, autonomy and social environment. The objectives of AF treatment in the elderly are to prevent AF complications, particularly stroke, and improve quality of life. Specific precautions for treatment must be taken because of the co-morbidities and age-related changes in pharmacokinetics or pharmacodynamics. Preventing AF complications relies mainly on anticoagulant therapy. Anticoagulants are recommended in patients with AF aged 75 years or above after assessing the bleeding risk using the HEMORR 2 HAGES or HAS-BLED scores. Novel oral anticoagulants (NOACs) are promising treatments, especially due to a lower risk of intracerebral haemorrhage. However, their prescriptions should take into account renal function (creatinine clearance assessed with Cockcroft formula) and cognitive function (for adherence to treatment). Studies including frail patients in “real life” are necessary to evaluate tolerance of NOACs. Management of AF also involves the treatment of underlying cardiomyopathy and heart rate control rather than a rhythm-control strategy as first-line therapy for elderly patients, especially if they are paucisymptomatic. Antiarrhythmic drugs should be used carefully in elderly patients because of the frequency of metabolic abnormalities and higher risk of drug interactions and bradycardia.


Résumé


La fibrillation atriale (FA) constitue un problème de santé publique avec entre 600 000 à un million de patients concernés en France dont les deux-tiers sont âgés de plus de 75 ans. La FA majore de risque mortalité et représente un facteur majeur de risque d’accident vasculaire cérébral ischémique (AVC). Chez la personne âgée en FA, les comorbidités sont fréquentes et aggravent le pronostic. La prise en charge de la FA du sujet âgé doit s’accompagner d’une évaluation gériatrique standardisée (EGS) qui apprécie les éléments médicaux, psychosociaux et permet une évaluation fonctionnelle du patient et de sa situation sociale. Elle conduit à identifier certaines comorbidités ou syndromes gériatriques (troubles cognitifs, chutes, dénutrition, dépression). Pour rendre l’évaluation gériatrique plus facile dans la pratique clinique, des tests courts de screening sont proposés, ils peuvent être complétés par une exploration plus complète réalisée par des équipes spécialisées de gériatrie. Les objectifs généraux du traitement restent applicables au sujet âgé : prévention des complications en particulier l’AVC, amélioration de la qualité de vie, réduction de la mortalité et des hospitalisations. Des précautions particulières d’utilisation des médicaments sont nécessaires en raison des comorbidités et de modifications pharmacocinétiques ou pharmacodynamiques liées au vieillissement. La prévention des complications repose essentiellement sur le traitement anticoagulant. Les anticoagulants sont recommandés après 75 ans en cas de FA après évaluation du risque hémorragique en utilisant les scores HEMORR 2 HAGES ou HAS-BLED. Les nouveaux anticoagulants sont prometteurs pour la prise en charge des malades âgés en FA non valvulaire, en particulier en raison du moindre risque d’hémorragie cérébrale. Toutefois, leur utilisation nécessite la prise en compte la fonction rénale (clairance de la créatinine selon la formule de Cockcroft) et du fonctionnement cognitif (observance thérapeutique). La réalisation d’études menées spécifiquement dans les populations de patients très âgés polypathologiques est nécessaire pour évaluer leur tolérance en situation de « vie réelle ». La prise en charge comprend aussi le traitement de la cardiopathie sous-jacente et la gestion du rythme cardiaque. Chez les personnes âgées, la stratégie du contrôle de fréquence cardiaque doit être privilégiée par rapport à celle du contrôle du rythme dans la majorité des cas. L’emploi des anti-arythmiques doit être prudent du fait des anomalies métaboliques fréquentes et d’un plus grand risque d’interaction médicamenteuse et de bradycardie.


Definition


Atrial fibrillation (AF) is an arrhythmia characterized by disorganized atrial activation with consequent deterioration of atrial mechanical function . Clinically, AF is suspected in case of irregularity in pulse and heart rate. The diagnosis is made by means of an electrocardiogram (ECG) showing the absence of P wave undulating baseline and irregular ventricular response when atrioventricular conduction is normal.


The underlying mechanism usually involves multiple micro–re-entry circuits. In some cases, AF is due to abnormal ectopic foci located in the pulmonary veins . Other atrial arrhythmias can occur in patients with AF, such as atrial tachycardia or atrial flutter.




Classification


Several classifications of AF have been proposed, based on ECG features or clinical presentation. The “three-P” classification is consensual: paroxysmal, persistent and permanent. AF is paroxysmal if it is self-terminating, usually within 48 hours; AF paroxysms may continue for up to 7 days. AF is persistent if the episode lasts for more than 7 days and is not terminated spontaneously. AF is permanent if all recorded ECGs show AF over an extended period (in general > 1 year). Persistent AF becomes permanent AF when cardioversion is not attempted or is unsuccessful.


When a patient is seen for the first time for AF and the arrhythmia was not previously known, it is called first-detected AF. The evolution of first-detected AF to a paroxysmal, persistent or permanent pattern is unpredictable ( Fig. 1 ). Paroxysmal AF is often recurrent.




Figure 1


Classification of atrial fibrillation. 1: an episode that lasts less than or 7 days (often < 24 hours); 2: an episode that lasts more than 7 days; 3: cardioversion is unsuccessful or it is not attempted. Note that paroxysmal and persistent fibrillations may be recurrent.




Epidemiology


AF constitutes a public health problem. It affects between 600,000 and 1 million patients in France, two-thirds of whom (i.e. 400,000 to 660,000 people) are aged above 75 years . The average annual cost per patient with AF is estimated to be 3000 euros . The total cost of the disease is about 2.5 billion euros, half of which is related to hospital expenses.


The prevalence of AF increases with age; it doubles each decade after the age of 50 years ( Fig. 2 ) and increases from less than 0.5% for those aged 40–50 years to 10–20% for those aged 80 years or above . Thus, 70% of AF patients are aged 75 years or above . This prevalence is probably underestimated because the methods used in epidemiological studies poorly detect paroxysmal AF .




Figure 2


Prevalence of atrial fibrillation stratified by age and sex in published studies since 1991: 1: ; 2: ; 3: ; 4: ; 5: ; 6: ; 7: ; 8: ; 9: ; 10: .


The prevalence of AF is higher among men than women. However, the number of women with AF appears to be higher due to the longer life expectancy for women . Lastly, AF prevalence has increased in the past decades independent of population ageing . In the USA, the age- and sex-adjusted AF incidence was 3.04 per 1000 person-years in 1981, increasing to 3.68 in 2000 . Extrapolation to the French population yields a number of 200,000 new cases per year. Based on these elements, the number of patients with AF is expected to double or triple in the next decades.




Aetiologies and co-morbidities


Cardiac ageing is often associated with myocardial fibrosis and atrial dilation, which favour the occurrence of AF. All cardiac diseases (in particular ischaemic, valvular or hypertensive heart diseases) may be complicated by AF, especially at an advanced stage of their evolution. Main cardiovascular risk factors are also associated with the risk of AF . Among these factors, age and hypertension play a leading role. Lastly, a search for an extracardiac cause, such as bronchopneumonia, chronic obstructive pulmonary disease (COPD), pulmonary embolism, iatrogenic event, hypokalaemia, hyperthyroidism or sleep apnoea syndrome, should be carried out systematically.


In elderly people, co-morbidities are frequent and worsen the prognosis of AF. They can be the cause or the consequence of AF and their management is a major therapeutic objective.


Hypertension


Hypertension is the most frequent co-morbidity factor associated with AF in the elderly, with a prevalence varying from 40% to 70% . Hypertension significantly raises the incidence of AF and thromboembolic events . Recent works demonstrate the role of pulse pressure as a predictive factor for AF; they highlight the impact of arterial ageing on left ventricular hypertrophy in the mechanisms of electrophysiological alterations.


Blood pressure control seems to reduce the incidence of AF . Several meta-analyses suggest a protective effect of renin-angiotensin system blockers (angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers) on AF occurrence. However, this class-effect on reducing the incidence of AF recurrences has not been confirmed in a randomized trial . In any case, blood pressure control in patients with AF and hypertension is a major goal for the prevention of complications, particularly cerebral strokes.


Heart failure


The occurrence of heart failure modifies the prognosis of AF, with an increased risk of mortality and stroke , even in cases of heart failure with preserved ejection fraction. After the age of 75 years, the prevalence of AF is about 40% in patients with heart failure .


The interaction between AF and heart failure is complex and is a vicious circle . AF favours heart failure and heart failure raises the risk of AF development. Heart failure increases atrial pressures and volumes and thus increases atrial stretch; it also leads to neurohormonal activation, which generates electrical and anatomical remodelling responsible for modifications of atrial electrophysiological properties. On the other hand, AF favours heart failure because of the loss of atrial systole leading to a decrease in diastolic ventricular filling. Lastly, tachycardia and irregularity of ventricular cycles contribute to alterations of cardiac output.


Coronary heart disease


Coronary heart disease is a risk factor for AF ; it also presents a risk factor for stroke in the presence of AF. Particularly, the acceleration of heart rate and the irregularity of cycles increase myocardial oxygen consumption and may alter coronary output.


Diabetes mellitus


Diabetes mellitus constitutes a risk factor for AF and a risk factor for stroke in the presence of AF . The explanatory factors of this association are numerous: arterial hypertension, coronary heart disease, altered sympathetic tone, “direct toxicity” of glucose on atrial structure, deterioration of diastolic function, alteration of atrial endothelial function and more frequent acute stress situations (infections, electrolyte anomalies, renal failure, etc.).


Obesity


Obesity is a risk factor for AF due to left atrial dilation, presence of high blood pressure or ventricular hypertrophy.


Respiratory insufficiency, COPD and sleep apnoea


Respiratory diseases, particularly sleep apnoea, are associated with AF due to oxygen desaturation episodes, fluctuations in sympathetic activity or modifications of intrathoracic pressure .




Prognosis and outcome


Mortality


AF is a predictive factor for mortality. Several observational studies show an increase in the risk of death from 50% to 90% in patients with AF compared with subjects of the same age in sinus rhythm . In the Euro Heart Survey (mean age, 66 years), the 1-year mortality of patients with AF was 5% (50% of deaths were due to cardiovascular causes) . In the BAFTA study (subjects aged > 75 years), the annual death rate was 8% (50% of deaths were due to cardiovascular causes) . The risk is higher among women, especially when cardiomyopathy or underlying heart failure is associated. Nevertheless, the increase in AF-related mortality seems to lower beyond the age of 75 years due to overmortality related to other causes .


Stroke


Stroke presents the main AF complication and accounts for 85% of embolic accidents due to AF. The annual incidence of stroke is similar in paroxysmal AF and permanent AF, varying from 1.5% to 3.3% . The main risk factors for the occurrence of stroke in AF patients are included in the CHADS 2 score ( Table 1 ): congestive heart failure, hypertension, age 75 years or above, diabetes (one point for each item) and prior stroke or transient ischaemic attack (two points). This score allows the evaluation of thromboembolic risk in AF.



Table 1

CHADS 2 and CHA 2 DS 2 -VASc scores.






























































CHADS 2 score CHA 2 DS 2 -VASc score
Items
Age ≥ 75 years 1 2
Age 65–74 years 0 1
Arterial hypertension 1 1
Diabetes 1 1
Heart failure or left ventricular dysfunction 1 1
Previous stroke or transient ischaemic attack 2 2
Female sex (if age > 65 years) 1
Vascular diseases (prior myocardial infarction, peripheral artery disease, aortic plaque) 1
Anticoagulation
No therapy 0
Aspirin a 0
Aspirin a or anticoagulant therapy 1
Anticoagulant therapy ≥ 2 1 or ≥ 2

Adapted from Camm et al. .

a 75–325 mg daily.



The European Society of Cardiology (ESC) guidelines 2012 focused update recommended use of the CHA 2 DS 2 -VASc risk score ( Table 1 ) to assess stroke risk in patients with AF. This score includes three further risk factors: female sex, age 65–74 years and history of cardiovascular diseases ( Table 1 ).


The risk of stroke increases with age, which is an item in the CHADS 2 score (≥ 75 years) as well as in the CHA 2 DS 2 -VASc score (moderate risk from 65–74 years, high risk if aged ≥ 75 years). AF is a major risk factor for stroke in the elderly: the risk of stroke related to AF is 2% for age less than 70 years, 24% for age 80–89 years and 35% for age above 90 years ( Fig. 3 ) . In the elderly, 80% of strokes are ischaemic and 20% are haemorrhagic .




Figure 3


Risk of atrial fibrillation-related stroke according to age.

Adapted from Wolf et al. .


AF-related strokes seem to be more severe than those unrelated to AF, with an increased 30-day mortality of 27–57%, 2-fold mortality and recurrences at 1 year and more severe disability at 3 months (75% of patients with AF are dependent compared with 36% of those without AF) .


Other cardiovascular events


AF is associated with a high annual incidence of cardiovascular events. In the Euro Heart Survey , 11% of AF patients had heart failure (one-third of whom had new onset heart failure), 6% had coronary events and 49% of cases needed hospitalization, 75% for cardiovascular causes.


Hospitalizations


In France in 2008, an analysis of the database of the electronic medical record system (PMSI) showed that AF was the main diagnosis in 84,000 hospitalizations and one of the associated diagnoses in 349,000 hospitalizations. This accounts for a total of 412,000 patients and a total of 610,198 hospitalizations . The number of AF hospitalizations has increased by 26% over a 3-year period. Most of these patients (92%) were aged 60 years or above. Pathologies associated with AF were hypertension, cardiac diseases, heart failure, stroke, syncope and renal dialysis. The death rate among these patients was 5.6%. It has been estimated that each year, 41% of AF patients are hospitalized; of these, 8% are hospitalized for a direct AF-related problem.


Cognitive disorders


Several epidemiological studies suggest that AF increases the risk of cognitive disorders and dementias . A recent meta-analysis, including 21 studies and 95,427 subjects, showed a significant association between AF and cognitive impairment or dementia (relative risk 1.40, 95% CI 1.19–1.64), both in patients with or without history of stroke . This cognitive alteration could be due to common risk factors (hypertension, diabetes), the occurrence of cerebral microemboli or fluctuations of cerebral perfusion. Cognitive disorders in elderly patients with AF must be detected and assessed because of their impact on prognosis, autonomy, understanding instructions and adherence to treatment (cf. paragraph on comprehensive geriatric assessment [CGA]).


Quality of life


Elderly patients with AF have a poorer quality of life compared with other people of the same age. Rhythm- or rate-control strategies allow significant improvement in quality of life .




Diagnosis


Clinical presentations


In the elderly, AF is often asymptomatic and an incidental finding . Palpitations are less frequent in elderly patients compared with younger adults . When present, AF symptoms are diverse : dyspnoea, palpitations, thoracic pain, faintnesses, falls, syncope, asthenia, anxiety, etc. AF can also be discovered when a complication, such as an embolic accident or heart failure, occurs.


AF in the elderly is often of acute onset during the course of stress secondary to an infectious episode (particularly bronchopneumonia), a surgical procedure and cardiac or respiratory decompensation. The occurrence of AF in the elderly indicates a high probability of an underlying cardiovascular disease and a higher risk of AF recurrence compared with that in younger people.


Clinical assessment


The aim of the clinical assessment is to define the type of AF (paroxysmal, persistent or permanent), to specify the illness history and to evaluate symptoms, trigger factors, cardiovascular diseases, complications, co-morbidities and current therapeutics.


History of atrial fibrillation


The history of AF in elderly patients is often difficult to reconstitute; questioning the patient’s family circle and/or general practitioner may be necessary. A trigger factor must be systematically sought: infectious episode, cardiac or respiratory decompensation, myocardial ischaemia, electrolyte disorders (hypokalaemia), hyperthyroidism, iatrogenic factors, diuretics, theophylline, salbutamol, etc.


Ventricular rate


Searching for pulse irregularity should be done systematically. Pulse palpation has a high sensitivity but low specificity for AF . The diagnosis of AF must be confirmed by an ECG. A very rapid ventricular rate suggests an associated extracardiac factor, especially in case of well-tolerated permanent AF. Bradyarrhythmia may be due to an iatrogenic effect (antiarrhythmic drugs, digitalis, calcium channel antagonists, inhibitors of cholinesterase, beta-blockers) or an associated conduction disorder.


Comprehensive assessment of the elderly subject with atrial fibrillation


It is necessary to look for co-morbidities and complications of AF, evaluate the thromboembolic and haemorrhagic risks and carry out a CGA.


Diagnostic tests


Twelve-lead ECG


A 12-lead ECG is indispensable to confirm the diagnosis ( Table 2 ). When paroxysmal AF is suspected, repeated ECG monitoring or long-term recordings should be considered. When AF is associated with a slow ventricular rate, an atrioventricular block should be suspected.



Table 2

Diagnostic tests in elderly people with atrial fibrillation (AF).


































































Tests Indication Awaited result
ECG Systematic Diagnosis of AF
ECG Holter recording Non-systematic unless syncope, faintness, unexplained heart failure Searching for bradycardia, heart pauses, rapid ventricular rate
Transthoracic echocardiography Systematic Searching for heart disease, left atrium dimensions, left ventricular function
Transoesophageal echocardiography Non-systematic unless rapid cardioversion is indicated Intracavitary thrombus
Chest X-ray Non-systematic Cardiomegaly, signs of pulmonary oedema
BNP, troponin Non-systematic
Blood cell count, serum electrolytes, creatinine, glycaemia, haemostasis test Systematic Searching for anaemia, creatinine clearance calculation, potassium disorders, diabetes, haemostasis disorder
Thyroid-stimulating hormone Systematic Hyperthyroidism
Serum digoxin level Non-systematic unless overdose is suspected
Liver function tests, CRP Non-systematic unless clinical suspicions

BNP: B-type natriuretic protein; CRP: C-reactive protein; ECG: electrocardiogram.


Chest X-ray


A chest X-ray allows heart size measurement and analysis of the pulmonary parenchyma (interstitial oedema, pneumonia, pulmonary sequelae); it helps detection of interstitial pneumonia due to long-term amiodarone therapy.


Ambulatory long-term ECG recordings


Ambulatory long-term ECG recordings can be useful to confirm paroxysmal AF or in case of symptoms that can be related to a slow ventricular rate (syncope, faintness) or a very rapid ventricular rate despite treatment.


Transthoracic echocardiography


Transthoracic echocardiography is recommended in all AF patients; it is used to detect ventricular, valvular and atrial disease. The presence or absence of an underlying cardiomyopathy is important for the choice of antiarrhythmic and antithrombotic drugs.


Transoesophageal echocardiography


Transoesophageal echocardiography is the only examination that enables the analysis of intra-atrial thrombosis; it is, however, rarely carried out in the elderly. The two main indications are: reversion to sinus rhythm without prior effective anticoagulation (for at least 3 weeks); and a search for the underlying cause in case of recurrent stroke or transient ischaemic attack of unknown aetiology.


Blood tests


A systematic work-up must be carried out: complete blood count, international normalized ratio (INR) for patients on a vitamin K antagonist, partial thromboplastin time, serum electrolytes, creatinine (with its clearance calculated by the Cockcroft formula), glycaemia and thyroid-stimulating hormone. According to the clinical picture, the following tests can be added: troponin assay, C-reactive protein, liver function tests, serum albumin and urine test strip ± urine culture. This work-up is necessary for the detection of trigger factors and for therapeutic management.




Comprehensive geriatric assessment


The management of AF in an elderly subject should involve a CGA, which analyses both medical and psychosocial elements, enabling evaluation of the patient’s functional status and social situation and identification of co-morbidities.


The CGA enables the detection of “frailty”, which is characterized by decreased physiological adaptation to stress or environmental changes, whether associated with organ failure. Short screening tools are proposed to make CGA easier and quicker to complete in clinical practice. If screening tests are abnormal, an intensive exploration by specialized geriatric teams must be launched ( Table 3 ). The principal elements of the CGA are outlined below.



Table 3

Geriatric assessment of elderly people with atrial fibrillation.































































Dimension Brief screening More complete assessment Interpretation
Cognitive function MIS (score 0–8) MMSE (score 0–30) Cognitive disorders if: immediate and/or delayed MIS ≤ 6; or five words < 9; or clock test abnormal; or abnormal CODEX; or MMSE ≤ 27 (or ≤ 24 if low educational level)
Clock test (normal/abnormal) Neuropsychological tests
CODEX (normal/abnormal)
Dependency Four-item IADL (score 0–4) IADL (score 0–14) Possible dependency if four-item IADL < 4
Dependency if IADL < 14
ADL (score 0–6) Severe dependency if ADL < 6
Depressive symptoms Mini GDS (score 0–4) GDS (score 0–30) Possible depression if Mini GDS ≥ 1
Probable depression if GDS ≥ 15
Nutritional status Weight variation MNA (score 0–30) Malnutrition if: weight loss > 5% in 1 month; or > 10% in 6 months; or MNA < 17; or serum albumin < 35 g/L
Serum albumin
Risk of fall One-leg balance test TUG test High risk of fall if; one-leg balance test < 5 s; and/or TUG > 20 s
Living condition Interview with patient and family Social isolation, safety of the treatment and follow-up organization

ADL: Activities of Daily Living; CODEX: Cognitive Disorders Examination; GDS: Geriatric Depression Scale; IADL: Instrumental Activities of Daily Living; MIS: Memory Impairment Screen; MMSE: Mini Mental State Examination; MNA: Mini Nutritional Assessment; TUG: Timed Up and Go.


Assessment of cognitive function


Evaluation of cognitive function is important in elderly AF patients for several reasons: it assesses the quality of the information obtained from the subjects (regarding memory disorders and the absence of functional complaint in anosognosic patients), the ability to understand instructions and the potential for therapeutic observance and adherence to treatment, particularly antithrombotics. Medical history and clinical examination are not enough to detect mild cognitive impairment (MCI); only cognitive assessment using a test can reveal MCI. The Mini Mental State Examination (MMSE) is a simple and brief standardized 30-point test that is used for screening cognitive disorders ( Appendix 1 ). The threshold value depends on the age and educational level of the patient. A score greater than 27 is considered normal. A score less than 24 is abnormal and should lead to a more detailed evaluation of the cognitive functions in a specialized setting. A score between 24 and 27 has to be considered abnormal, especially when the patient is not very old (age < 80 years), has a high educational level and has symptoms involving the memory or other cognitive functions. An abnormal MMSE score indicates cognitive dysfunction not necessarily related to dementia. This is why an abnormal score is not enough to confirm the diagnosis and further specialized assessment is required. More rapid tests can be used to detect cognitive disorders in the elderly, such as the Memory Impairment Screen (MIS) ( Appendix 2 ), CODEX ( Appendix 3 ), the five-word test, the clock test, etc. Whatever the test used, abnormal results indicate a strong probability of cognitive disorders and indicate the need for a specialized assessment.


Assessment of dependency


Dependency is defined as the need for support by a third person to carry out activities of daily living. Autonomy can be evaluated by scales that assess activities of daily life (Instrumental Activities of Daily Living and Activities of Daily Living ( Appendix 4 )) through questioning the patient and their relatives. The short form of the Instrumental Activities of Daily Living scale ( Appendix 5 ) includes the following four items: ability to use telephone, mode of transportation, responsibility for own medication and ability to handle finances. The Activities of Daily Living scale gives information about personal hygiene and grooming, dressing, ability to go to the toilet, transferring, continence and feeding autonomy. A subject is considered dependent when they need personal assistance in performing a given activity.


Gait disorders and risk of falls


The risk of fall related to postural instability plays a role in the therapeutic choice (cf. paragraph on falls and vitamin K antagonists). The assessment of the risk of fall is based on taking a history (history of falls), physical examination (general health status, neuromuscular status, joint status, vision and neurological and cardiovascular examination, searching for orthostatic hypotension in particular) and simple tests such as the one-leg balance test, which evaluates the ability to stand unaided for 5 seconds on one leg, and the Timed Up and Go test, which measures the time taken to stand up from a standard armchair, walk 3 m, turn around, walk back to the chair and sit down again. A time more than 20 seconds indicates a risk of falls.


Assessment of nutritional status


A systematic measurement of weight should be taken in elderly subjects. Malnutrition is defined as weight loss of above 5% in 1 month or above 10% in 6 months; it indicates the presence of an at-risk situation. Weight interpretation should consider clinical and biological elements of fluid retention or dehydration. The nutritional assessment can also be done by means of a validated scale (Mini Nutritional Assessment) and serum albumin. A Mini Nutritional Assessment score less than 17 or a serum albumin concentration less than 35 g/L indicates malnutrition.


Assessment of mood disorders


The Mini Geriatric Depression Scale is a rapid four-question screening test ( Appendix 6 ). In case of abnormal result, the complete Geriatric Depression Scale allows collection of depressive symptoms. A score of 15/30 or more indicates possible depression and a score greater than 22/30 indicates possible major depression. Depression in the elderly subject is associated with worse cardiovascular prognosis and lower compliance with treatment .


Assessment of living conditions


Assessment of living conditions aims to determine compliance with prescribed treatment. If patients cannot manage their own treatments, it is important to organize the administration of medication (purchase, preparation, use of a pill dispenser, involvement of family members, nurse or social worker). It is also important to determine the state of isolation of the patients and to consider the involvement of caregivers, as well access to various care services. Educating and informing patients and families about the disease is required in order to ensure medication administration and an understanding of the complications.

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Jul 12, 2017 | Posted by in CARDIOLOGY | Comments Off on Expert consensus of the French Society of Geriatrics and Gerontology and the French Society of Cardiology on the management of atrial fibrillation in elderly people

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