IMPORTANCE Epidemiological evidence suggests that physical activity benefits cognition, but results from randomized trials are limited and mixed.OBJECTIVE To determine whether a 24-month physical activity program results in better cognitive function, lower risk of mild cognitive impairment (MCI) or dementia, or both, compared with a health education program. DESIGN, SETTING, AND PARTICIPANTSA randomized clinical trial, the Lifestyle Interventions and Independence for Elders (LIFE) study, enrolled 1635 community-living participants at 8 US centers from February 2010 until December 2011. Participants were sedentary adults aged 70 to 89 years who were at risk for mobility disability but able to walk 400 m. INTERVENTIONS A structured, moderate-intensity physical activity program (n = 818) that included walking, resistance training, and flexibility exercises or a health education program (n = 817) of educational workshops and upper-extremity stretching. MAIN OUTCOMES AND MEASURES Prespecified secondary outcomes of the LIFE study included cognitive function measured by the Digit Symbol Coding (DSC) task subtest of the Wechsler Adult Intelligence Scale (score range: 0-133; higher scores indicate better function) and the revised Hopkins Verbal Learning Test (HVLT-R; 12-item word list recall task) assessed in 1476 participants (90.3%). Tertiary outcomes included global and executive cognitive function and incident MCI or dementia at 24 months.RESULTS At 24 months, DSC task and HVLT-R scores (adjusted for clinic site, sex, and baseline values) were not different between groups. The mean DSC task scores were 46.26 points for the physical activity group vs 46.28 for the health education group (mean difference, −0.01 points [95% CI, −0.80 to 0.77 points], P = .97). The mean HVLT-R delayed recall scores were 7.22 for the physical activity group vs 7.25 for the health education group (mean difference, −0.03 words [95% CI, −0.29 to 0.24 words], P = .84). No differences for any other cognitive or composite measures were observed. Participants in the physical activity group who were 80 years or older (n = 307) and those with poorer baseline physical performance (n = 328) had better changes in executive function composite scores compared with the health education group (P = .01 for interaction for both comparisons). Incident MCI or dementia occurred in 98 participants (13.2%) in the physical activity group and 91 participants (12.1%) in the health education group (odds ratio, 1.08 [95% CI, 0.80 to 1.46]).CONCLUSIONS AND RELEVANCE Among sedentary older adults, a 24-month moderate-intensity physical activity program compared with a health education program did not result in improvements in global or domain-specific cognitive function.

Caring for older adults with multiple chronic conditions (MCCs) is challenging. The American Geriatrics Society (AGS) previously developed The AGS Guiding Principles for the Care of Older Adults With Multimorbidity using a systematic review of the literature and consensus. The objective of the current work was to translate these principles into a framework of Actions and accompanying Action Steps for decision making for clinicians who provide both primary and specialty care to older people with MCCs. A work group of geriatricians, cardiologists, and generalists: (1) articulated the core MCC Actions and the Action Steps needed to carry out the Actions; (2) provided decisional tips and communication scripts for implementing the Actions and Action Steps, using commonly encountered situations: (3) performed a scoping review to identify evidence‐based, validated tools for carrying out the MCC Actions and Action Steps; and (4) identified potential barriers to, and mitigating factors for, implementing the MCC Actions. The recommended MCC Actions include: (1) identify and communicate patients' health priorities and health trajectory; (2) stop, start, or continue care based on health priorities, potential benefit vs harm and burden, and health trajectory; and (3) align decisions and care among patients, caregivers, and other clinicians with patients' health priorities and health trajectory. The tips and scripts for carrying out these Actions are included in the full MCC Action Framework available in the supplement (http://www.geriatricscareonline.org). J Am Geriatr Soc 67:665–673, 2019.

Background Despite the fact that 80% of patients with heart failure are over age 65, recognition of cognitive impairment by physicians in this population has received relatively little attention. The purpose of our study was to evaluate physician documentation (as a measure of recognition) of cognitive impairment at time of discharge in a cohort of older adults hospitalized for heart failure. Methods We performed a prospective cohort study of older adults hospitalized with a primary diagnosis of heart failure. Cognitive status was evaluated with the Folstein Mini-Mental State Examination (MMSE) at the time of hospitalization. A score of 21–24 was used to indicate mild cognitive impairment, and a score of ≤20 to indicate moderate to severe impairment. To evaluate physician documentation of cognitive impairment, we used a standardized form with a targeted keyword strategy to review hospital discharge summaries. We calculated the proportion of patients with cognitive impairment documented as such by physicians, and compared characteristics between groups with and without documented cognitive impairment. We then analyzed the association of cognitive impairment, and documentation of cognitive impairment, with 6-month mortality or readmission using Cox proportional hazards regression. Results A total of 282 patients completed the cognitive assessment. Their mean age was 80 years of age, 18.8% were nonwhite, and 53.2% were female. Cognitive impairment was present in 132/282 patients (46.8% overall; 25.2% mild, 21.6% moderate-severe). Among those with cognitive impairment, 30/132 (22.7%) were documented as such by physicians. Compared with patients whose cognitive impairment was documented by physicians, those whose impairment was not documented were younger (81.3 years vs. 85.2 years, P<0.05) and had less severe impairment (median MMSE score 22.0 vs. 18.0, P<0.01). After multivariable adjustment, patients whose cognitive impairment was not documented were significantly more likely to experience 6-month mortality or hospital readmission than patients without cognitive impairment. Conclusions Cognitive impairment is common in older adults hospitalized for heart failure, yet frequently not documented by physicians. Implementation of strategies to improve recognition and documentation of cognitive impairment may improve the care of these patients, particularly at the time of hospital discharge.

Decision making in cardiology concentrates on diseasespecific outcomes following practice guidelines for specific conditions. Quality metrics implemented for valuebased purchasing and public reporting also largely focus on individual diseases. Disease-centered approaches are appropriate when individuals have a single predominant disease and everyone with the disease desires the same outcome, such as prolonged survival or stroke prevention. 1 This disease-centered framework is illsuited, however, for persons with multiple chronic conditions, including most older adults with cardiovascular conditions and the majority of adult health care users of all ages. 2 Disease-centered decision making for this population results in treatment burden when patients must adhere to multiple guidelines and harm when guideline recommendations conflict. 3 Furthermore, disease-centered recommendations may not address what matters most to these patients who vary in their health priorities. 4 To consider an alternative to disease-centered decision making that better aligns care with what matters most to patients and reduces treatment burden, it is helpful to think of health care decisions as value propositions in which value = health outcome / cost. From the population perspective, health care value is defined as survival or disease benefit (output) per dollar spent (input). From patients' perspective, however, the personal health outcomes that they hope to achieve are more appropriate outputs. 4 The appropriate inputs may include financial costs, but often more relevant are costs in terms of the time, discomfort, harms, and workload required to achieve their health outcomes. 3 When defined as what patients are willing and able to do for their health, these broader costs inform care preferences. An alternative approach to decision making, therefore, is predicated on achieving patients' specific health outcome goals within the context of their acceptable workload. High-value care is defined as achievement of each patient's highest-level health outcome goals given the workload each is willing and able to perform. This is not as daunting a task as it may seem; patients implicitly consider trade-offs between outcome and workload even if it is not explicitly discussed. 3 Examples of health outcome goals and patient workload are shown in the Box. This approach represents a shift from diseasecentered to patient goals-directed care. The idea that health care decisions should include patients' health

OBJECTIVES This study sought to determine whether the extent of late gadolinium enhancement (LGE) can provide additive prognostic information in patients with a nonischemic dilated cardiomyopathy (NIDC) with an indication for implantable cardioverter-defibrillator (ICD) therapy for the primary prevention of sudden cardiac death (SCD). BACKGROUND Data suggest that the presence of LGE is a strong discriminator of events in patients with NIDC. Limited data exist on the role of LGE quantification. METHODS The extent of LGE and clinical follow-up were assessed in 162 patients with NIDC prior to ICD insertion for primary prevention of SCD. LGE extent was quantified using both the standard deviation–based (2-SD) method and the full-width half-maximum (FWHM) method. RESULTS We studied 162 patients with NIDC (65% male; mean age: 55 years; left ventricular ejection fraction [LVEF]: 26 ± 8%) and followed up for major adverse cardiac events (MACE), including cardiovascular death and appropriate ICD therapy, for a mean of 29 ± 18 months. Annual MACE rates were substantially higher in patients with LGE (24%) than in those without LGE (2%). By univariate association, the presence and the extent of LGE demonstrated the strongest associations with MACE (LGE presence, hazard ratio [HR]: 14.5 [95% confidence interval (CI): 6.1 to 32.6; p < 0.001]; LGE extent, HR: 1.15 per 1% increase in volume of LGE [95% CI: 1.12 to 1.18; p < 0.0001]). Multivariate analyses showed that LGE extent was the strongest predictor in the best overall model for MACE, and a 7-fold hazard was observed per 10% LGE extent after adjustments for patient age, sex, and LVEF (adjusted HR: 7.61; p < 0.0001). LGE quantitation by 2-SD and FWHM both demonstrated robust prognostic association, with the highest MACE rate observed in patients with LGE involving >6.1% of LV myocardium. CONCLUSIONS LGE extent may provide further risk stratification in patients with NIDC with a current indication for ICD implantation for the primary prevention of SCD. Strategic guidance on ICD therapy by cardiac magnetic resonance in patients with NIDC warrants further study.