As discussed in Tafamidis for Transthyretin Cardiac Amyloidosis: Part 1, an 89-year-old man with progressive effort intolerance, abdominal bloating, and lower extremity edema presented for evaluation of heart failure (HF) in the setting of preserved ejection fraction. Further information is now available on his geriatric conditions.

Given his obvious geriatric comorbidities, he is referred to see a geriatrician. A careful evaluation of his instrumental activities of daily living (IADL) and activities of daily living (ADL) is conducted. His disability degree is evaluated as independent (I), complete assistance (C), or any type of assistance (A), with the following results:

ADL:

• Feeding: A
• Dressing and undressing: A
• Grooming: A
• Walking (or using a walker): I
• Getting in and out of bed: I
• Toileting: A
• Bathing or showering: A

IADL:

• Using the telephone: I
• Using transportation: C (after his stroke)
• Shopping: C
• Pulling or pushing a large object: C
• Scooping, crouching, or kneeling: C
• Lifting or carrying 4.5 kg (10 lbs): A
• Reaching arms above shoulders: C (on the side of his stroke)
• Writing or handing small objects: C (on the side of his stroke)
• Walking up a flight of stairs: I (if handles are present)
• Walking 0.8 km (0.5 mi): C
• Heavy work around the house: C

He is right-handed. His disability status demonstrates the inability to perform tasks on the basis of substantially decreased mobility on the left side due to hemiparesis/hemiplegia from the stroke. He is currently managing his money with his wife (as he has always done) and independently managing his own medications with no mistakes. His higher physical function has substantially decreased because of his stroke.

He has excellent social support and is accompanied to all his appointments by his daughter, who is a strong advocate for his health needs. He has significant resources and has been able to afford home health aides who help with his ADL 24 hours a day, 7 days a week.

A cognitive assessment is performed using the Montreal Cognitive Assessment (MOCA), revealing a score of 23 of 30. His Functional Activities Questionnaire (FAQ) score is 7, based on the scoring system of normal (0), has never done the ADL but could do it now (0), has never done the ADL and would have difficulty now (1), has difficulty with the ADL but does it by himself (1), requires assistance (2), and dependent (3).¹ The ratings are determined as follows¹:

• 0 = assembling tax records, business affairs, or papers; playing a game of skill, working on a hobby; heating water, making a cup of coffee, turning off stove after use
• 1 = writing checks, paying bills, balancing checkbook; shopping alone for clothes, household necessities, or groceries; preparing a balanced meal; keeping track of current events; paying attention to, understanding, discussing television, book, magazine; remembering appointments, family occasions, holidays, medications
• 2 = traveling out of neighborhood, driving, arranging to take buses.

Based on his assessment of his disabilities, MOCA score, and FAQ score, a diagnosis of minor cognitive impairment is made. In addition to his recently diagnosed transthyretin cardiac amyloidosis, he has several other medical conditions including arthritis, anemia, chronic kidney disease, benign prostatic hyperplasia with urinary frequency, lumbar spinal stenosis, hearing loss, and glaucoma. He takes 12 medications daily. He has New York Heart Association (NYHA) class IIIb HF symptoms.

References

1. Pfeffer RI, Kurosaki TT, Harrah CH Jr, Chance JM, Filos S. Measurement of functional activities in older adults in the community. J Gerontol 1982;37:323-29.
2. Maurer MS, Schwartz JH, Gundapaneni B, et al.; ATTR-ACT Study Investigators. Tafamidis treatment for patients with transthyretin amyloid cardiomyopathy. N Engl J Med 2018;379:1007-16.
3. Elliott P, Gundapaneni B, Sultan MB, Ines M, Garcia-Pavia P. Improved long-term survival with tafamidis treatment in patients with transthyretin amyloid cardiomyopathy and severe heart failure symptoms. Eur J Heart Fail 2023;25:2060-4.
4. Ruberg FL, Grogan M, Hanna M, Kelly JW, Maurer MS. Transthyretin amyloid cardiomyopathy: JACC state-of-the-art review. J Am Coll Cardiol 2019;73:2872-91.
5. Garcia-Pavia P, Sultan MB, Gundapaneni B, et al. Tafamidis efficacy among octogenarian patients in the phase 3 ATTR-ACT and ongoing long-term extension study. JACC Heart Fail 2024;12:150-60.
6. Fine NM, McMillan JM. Prevalence and prognostic significance of frailty among patients with transthyretin amyloidosis cardiomyopathy. Circ Heart Fail 2021;14:[ePub ahead of print].
7. Cazalbou S, Naccache L, Sourdet S, et al.; The Toulouse Amyloidosis Research Network. Frailty in older patients with transthyretin cardiac amyloidosis. J Clin Med 2023;12:7507.
8. Broussier A, David JP, Kharoubi M, et al. Frailty in wild-type transthyretin cardiac amyloidosis: the tip of the iceberg. J Clin Med 2021;10:3415.