Population-Based Multilevel Models to Estimate the Management Strategies for Acute Myocardial Infarction in Older Adults with Dementia

Abstract

Background Acute myocardial infarction (AMI) management strategies, involving treatment and post-care, are much more difficult for patients with dementia. This study investigated the factors influencing the use of invasive procedures and long-term care in the management strategies for AMI patients with dementia and the factors associated with these patients’ survival. Methods This multilevel study combined information from two databases, namely later-stage elderly healthcare insurance and long-term care insurance claims, from 2013 to 2019. Of 214,963 individuals with dementia, we identified 13,593 patients with AMI. The primary outcomes were the use of invasive procedures for treatment and long-term care for post-care management. Survival outcomes were also measured over a 6-year period, adjusting for individual- and regional-level characteristics in multilevel models. Results A total of 1954 (14.38%) individuals received an invasive procedure during treatment, and 7850 (87.18%) used long-term care for post-care management after AMI. After multivariate adjustment, patients aged ≥ 85 years and women were less likely to receive invasive procedures and more likely to use long-term care. Patients undergoing invasive procedures had a lower use of long-term care. Better survival outcome was significantly associated with invasive management and long-term care, regardless of the type of care. Conclusion Age and sex determine the use of invasive procedures and long-term care after AMI among patients with dementia. AMI patients with dementia receiving invasive procedures and long-term care had better survival outcomes.

Prognostic Impact of Percutaneous Coronary Intervention in Older Patients Hospitalized with Acute Myocardial Infarction: Real-World Findings from the Lombardy Health Database

“…This is mainly due to the underrepresentation or exclusion of elderly patients from major clinical trials of cardiovascular interventions, largely because of concerns about the increased risk of adverse events, complexity of followup, and limited life expectancy [1,2]. However, data from registries, hospital cohorts, and subgroup analyses from randomized trials have recently indicated beneficial effects on the outcome of PCI use irrespective of age in AMI patients [13][14][15][16][17][18]. As PCI remains underused in older patients, additional data are needed to confirm whether PCI is associated with a clinical benefit in this group of patients [3][4][5][13][14][15][16][17][18].…”

“…However, data from registries, hospital cohorts, and subgroup analyses from randomized trials have recently indicated beneficial effects on the outcome of PCI use irrespective of age in AMI patients [13][14][15][16][17][18]. As PCI remains underused in older patients, additional data are needed to confirm whether PCI is associated with a clinical benefit in this group of patients [3][4][5][13][14][15][16][17][18]. On these bases, we aimed at analyzing a large real-world administrative dataset to confirm the significant benefit described by metaanalyses of randomized trials comparing PCI with drug therapy in patients aged ≥75 years hospitalized with AMI [19,20].…”

“…To the best of our knowledge, ours is the largest study population focused on AMI patients older than 75 years, as almost all other studies included less than 3000-4000 patients [3][4][5][11][12][13][14][15][16][17][18][19][20]22]. Only one administrative Spanish study can be compared to ours [16].…”

Final benefit of primary percutaneous coronary intervention for ST-elevation myocardial infarction in older patients: long-term results of a randomised trial

“…Since the benefit of primary PCI in older patients with STEMI has been demonstrated in both randomised and observational studies, also in those with a serious comorbidity such as dementia [11], there should be discussion as to which subgroups of older patients should not be treated invasively. These subgroups may include patients with either a serious comorbidity such as severe dementia or those who present with a very poor cardiac prognosis (such as those with a very high age and cardiogenic shock).…”

Management of Coronary Artery Disease in Older Adults: Recent Advances and Gaps in Evidence

“…In the acute setting, individuals with mild CI (MCI) or pre-existing dementia may experience further deterioration in cognitive function beyond their baseline level due to the stress of the acute event, an unfamiliar environment, or side effects of medications [ 126 ]. In a comprehensive multilevel study, data from two databases were included, namely later-stage elderly healthcare insurance and long-term care insurance claims, spanning the period from 2013 to 2019 [ 127 ]. Among a total of 214,963 individuals diagnosed with dementia, 13,593 experienced an acute myocardial infarction (AMI) [ 127 ].…”