- Email: [email protected]
Top 10 List for the Cardiovascular Care of Older Adults
Accepted Manuscript Top 10 List for the Cardiovascular Care of Older Adults Karen P. Alexander, MD, Michael W. Rich, MD, Daniel E. Forman, MD, Nanette K. Wenger, MD, John A. Dodson, MD, Joseph S. Alpert, MD, James N. Kirkpatrick, MD, Mathew S. Maurer, MD PII:
S0002-9343(16)30472-7
DOI:
10.1016/j.amjmed.2016.04.031
Reference:
AJM 13520
To appear in:
The American Journal of Medicine
Received Date: 24 March 2016 Revised Date:
22 April 2016
Accepted Date: 25 April 2016
Please cite this article as: Alexander KP, Rich MW, Forman DE, Wenger NK, Dodson JA, Alpert JS, Kirkpatrick JN, Maurer MS, Top 10 List for the Cardiovascular Care of Older Adults, The American Journal of Medicine (2016), doi: 10.1016/j.amjmed.2016.04.031. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Top 10 List for the Cardiovascular Care of Older Adults Karen P. Alexander MD1, Michael W. Rich MD2, Daniel E. Forman MD3, Nanette K. Wenger MD4, John A.
RI PT
Dodson MD5, Joseph S. Alpert MD6, James N. Kirkpatrick MD7, Mathew S. Maurer MD8 Duke University and Duke Clinical Research Institute, Durham NC1, Washington University, St Louis MO,2 University of Pittsburgh, Pittsburg PA,3 Emory University, Atlanta GA4, New York University, New York
M AN U
New York NY. 8
SC
NY5, University of Arizona, Tuscon AZ6, University of Washington, Seattle WA7, and Columbia University,
Word Count: 892 Running Head: Top 10 List
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Corresponding Author: Karen P. Alexander MD, Duke Clinical Research Institute, 2400 Pratt Street, Durham NC 27710. Email: [email protected] Phone:(919) 668-8871 Author Contribution: All authors participated in the conceptualization, generation and approval the manuscript. Funding: None
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EP
Conflicts of Interest: None
ACCEPTED MANUSCRIPT
Cardiovascular medicine is disease-oriented, technology-driven, evidence-rich, and focused on saving lives. Geriatric medicine is syndrome-oriented, technology-avoiding, multidisciplinary, and
RI PT
focused on preserving quality of life. The tenets of these disciplines are divergent, yet their integration affords a richer platform for the cardiovascular care of older adults. (1) Cardiovascular guidelines
recommend treatment based upon evidence gathered predominantly in 50-60 year olds. While a cardiac
SC
condition may exist in isolation in younger patients, at age 80 this is often not the case. In older adults, treatments may result in larger benefits given higher absolute risk, but can be offset by adverse effects
M AN U
attributable to age-related changes in the cardiovascular and other organ systems. Additionally, outcomes of interest to older adults differ from those in younger individuals. The heterogeneity of aging further adds to the inherent complexity of care. (2) Examples of healthy aging at the extremes of age, remind us that functional status and frailty as relevant as age itself in predicting the resiliency of an older patient. (3) Diagnosis and treatment plans must consider multiple interacting systems, where a
TE D
sudden change in function may be the only sign of a problem. Shortness of breath may result from COPD with just a mild degree of heart failure; worsening angina may result from worsening anemia in the context of an occult gastrointestinal bleed rather than progressive coronary disease; and an elevated
EP
troponin value may be from myocardial injury from hypoxemia in a patient with community-acquired
AC C
pneumonia, rather than an unstable coronary plaque. (4) Finally, while we advocate for the promise of modern medicine and pursue aggressive care in many, when we cannot cure, we must still care for our older patients. All practitioners should have a working knowledge of palliative care to enhance choices. (5) The list below highlights the top 10 ways to integrate these concepts for the cardiovascular care of older adults. 1. Older adults are not just adults with grey hair This headline is the geriatric equivalent of the pediatric maxim, “Children are not just small adults”. Aging is associated with substantial alterations in cardiovascular structure and function which influence
ACCEPTED MANUSCRIPT
pathophysiologic mechanisms, predispose to the development of cardiovascular disease, reduce cardiovascular reserves, and increase risk for adverse outcomes. Normal physiologic changes with aging alter safe and effective care. 2. Frailty is the vital sign of old age
RI PT
Frailty is a biological syndrome that reflects a state of decreased physiologic reserves and vulnerability to stressors. The majority of older adults are not frail, so identifying those who are is as important as detecting those who are not. Incorporate geriatric assessments as part of vital screening, as frailty, geriatric syndromes, and cognitive impairment are critical factors in older adults. 3. Embrace Complexity
4. Treat the cardiac condition in context
M AN U
SC
The passage of time is associated with increasing heterogeneity across individuals of the same chronologic age. Also, symptoms pose a great masquerade in older patients - worsening hypertension, fatigue, or dizziness may be atypical presentations of typical conditions. To prepare, think broadly and critically.
Cardiovascular disease in older adults almost never occurs in isolation, so optimal management requires consideration of comorbidities. 5. When in doubt, ask the patient (or family, or caregiver)
TE D
Shared decision-making is prefaced on adequate communication and understanding. Assessing knowledge, preferences, and goals of care often requires inclusion of caregivers and family as well as generational and cultural sensitivity. 6. Functional status and revitalization are key priorities of care
EP
Inactivity accelerates age-related declines in function. Cardiac rehabilitation, early mobilization in hospitalized patients, physical therapy and occupational therapy, out-patient rehabilitation including strengthening exercises, gait/balance, and aerobic training are vitally important to maximize function. Unfortunately, these are all under-utilized.
AC C
7. Caveat emptor for the use of evidence-based medicine in the care of older adults with cardiovascular disease Older patients are inherently at higher risk for adverse outcomes, however, the potential benefit of an intervention is often greater; therefore, age per se is rarely a contraindication to aggressive therapy. Yet, older patients, especially those with multiple chronic conditions, geriatric syndromes, and/or nursing home residence, have been under-represented in cardiovascular clinical trials; therefore, the applicability of trial findings the older population is less certain. 8. Less may be more Older patients are at risk for drug side effects, complications, and iatrogenesis. Providers should consider un-prescribing, practice slow medicine, and allow time to determine need for interventions when feasible.
ACCEPTED MANUSCRIPT
9. While you often can’t cure, don’t ever abandon
RI PT
Every technology is built for a purpose. Invasive procedures (i.e., coronary artery bypass grafting, implantable coronary defibrillator, destination left ventricular assist devices, andtranscatheter aortic valve replacement) should be undertaken for clearly defined and attainable goals of care. Even if not needing a procedure or intervention, optimal care can and should continue. 10. Palliative care and end of life discussions should be in the toolbox for care of older CV patients
M AN U
SC
Death is a certainty, yet a good death is often hard to come by. The best care considers quality of death and quality of life. Not all patients are able to discuss these issues, but avoiding the conversation risks missing an opportunity to provide better care. Palliative care can be helpful for all patients who need to choose among potentially complicated healthcare options. Helping patients, families and caregivers with these choices is at the center of health care. Goals of care can change over time, and so discussing early and during follow up is important.
References
1. Bell SP, Orr NM, Dodson JA, Rich MW, Wenger NK, Blum K, Harold JG, Tinetti ME, Maurer MS, Forman DE. What to Expect From the Evolving Field of Geriatric Cardiology. J Am Coll Cardiol. 2015 Sep 15;66(11):1286-99.
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EP
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2. Friedman SM, Shah K, Hall WJ. Failing to Focus on Healthy Aging: A Frailty of Our Discipline? J Am Geriatr Soc. 2015 Jul;63(7):1459-62 3. Afilalo J, Alexander KP, Mack MJ, Maurer MS, Green P, Allen LA, Popma JJ, Ferrucci L, Forman DE. Frailty assessment in the cardiovascular care of older adults. J Am Coll Cardiol. 2014 Mar 4;63(8):747-62 4. Sarkisian L, Saaby L, Poulsen TS, Gerke O, Jangaard N, Hosbond S, Diederichsen AC, Thygesen K, Mickley H.Clinical Characteristics and Outcomes of Patients with Myocardial Infarction, Myocardial Injury, and Nonelevated Troponins. Am J Med. 2016 Apr;129(4):446.e5-446.e21. 5. Quill TE, Abernethy AP. Generalist plus specialist palliative care—creating a more sustainable model. N Engl J Med 2013;368:1173–5
S0002-9343(16)30472-7
DOI:
10.1016/j.amjmed.2016.04.031
Reference:
AJM 13520
To appear in:
The American Journal of Medicine
Received Date: 24 March 2016 Revised Date:
22 April 2016
Accepted Date: 25 April 2016
Please cite this article as: Alexander KP, Rich MW, Forman DE, Wenger NK, Dodson JA, Alpert JS, Kirkpatrick JN, Maurer MS, Top 10 List for the Cardiovascular Care of Older Adults, The American Journal of Medicine (2016), doi: 10.1016/j.amjmed.2016.04.031. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Top 10 List for the Cardiovascular Care of Older Adults Karen P. Alexander MD1, Michael W. Rich MD2, Daniel E. Forman MD3, Nanette K. Wenger MD4, John A.
RI PT
Dodson MD5, Joseph S. Alpert MD6, James N. Kirkpatrick MD7, Mathew S. Maurer MD8 Duke University and Duke Clinical Research Institute, Durham NC1, Washington University, St Louis MO,2 University of Pittsburgh, Pittsburg PA,3 Emory University, Atlanta GA4, New York University, New York
M AN U
New York NY. 8
SC
NY5, University of Arizona, Tuscon AZ6, University of Washington, Seattle WA7, and Columbia University,
Word Count: 892 Running Head: Top 10 List
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Corresponding Author: Karen P. Alexander MD, Duke Clinical Research Institute, 2400 Pratt Street, Durham NC 27710. Email: [email protected] Phone:(919) 668-8871 Author Contribution: All authors participated in the conceptualization, generation and approval the manuscript. Funding: None
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EP
Conflicts of Interest: None
ACCEPTED MANUSCRIPT
Cardiovascular medicine is disease-oriented, technology-driven, evidence-rich, and focused on saving lives. Geriatric medicine is syndrome-oriented, technology-avoiding, multidisciplinary, and
RI PT
focused on preserving quality of life. The tenets of these disciplines are divergent, yet their integration affords a richer platform for the cardiovascular care of older adults. (1) Cardiovascular guidelines
recommend treatment based upon evidence gathered predominantly in 50-60 year olds. While a cardiac
SC
condition may exist in isolation in younger patients, at age 80 this is often not the case. In older adults, treatments may result in larger benefits given higher absolute risk, but can be offset by adverse effects
M AN U
attributable to age-related changes in the cardiovascular and other organ systems. Additionally, outcomes of interest to older adults differ from those in younger individuals. The heterogeneity of aging further adds to the inherent complexity of care. (2) Examples of healthy aging at the extremes of age, remind us that functional status and frailty as relevant as age itself in predicting the resiliency of an older patient. (3) Diagnosis and treatment plans must consider multiple interacting systems, where a
TE D
sudden change in function may be the only sign of a problem. Shortness of breath may result from COPD with just a mild degree of heart failure; worsening angina may result from worsening anemia in the context of an occult gastrointestinal bleed rather than progressive coronary disease; and an elevated
EP
troponin value may be from myocardial injury from hypoxemia in a patient with community-acquired
AC C
pneumonia, rather than an unstable coronary plaque. (4) Finally, while we advocate for the promise of modern medicine and pursue aggressive care in many, when we cannot cure, we must still care for our older patients. All practitioners should have a working knowledge of palliative care to enhance choices. (5) The list below highlights the top 10 ways to integrate these concepts for the cardiovascular care of older adults. 1. Older adults are not just adults with grey hair This headline is the geriatric equivalent of the pediatric maxim, “Children are not just small adults”. Aging is associated with substantial alterations in cardiovascular structure and function which influence
ACCEPTED MANUSCRIPT
pathophysiologic mechanisms, predispose to the development of cardiovascular disease, reduce cardiovascular reserves, and increase risk for adverse outcomes. Normal physiologic changes with aging alter safe and effective care. 2. Frailty is the vital sign of old age
RI PT
Frailty is a biological syndrome that reflects a state of decreased physiologic reserves and vulnerability to stressors. The majority of older adults are not frail, so identifying those who are is as important as detecting those who are not. Incorporate geriatric assessments as part of vital screening, as frailty, geriatric syndromes, and cognitive impairment are critical factors in older adults. 3. Embrace Complexity
4. Treat the cardiac condition in context
M AN U
SC
The passage of time is associated with increasing heterogeneity across individuals of the same chronologic age. Also, symptoms pose a great masquerade in older patients - worsening hypertension, fatigue, or dizziness may be atypical presentations of typical conditions. To prepare, think broadly and critically.
Cardiovascular disease in older adults almost never occurs in isolation, so optimal management requires consideration of comorbidities. 5. When in doubt, ask the patient (or family, or caregiver)
TE D
Shared decision-making is prefaced on adequate communication and understanding. Assessing knowledge, preferences, and goals of care often requires inclusion of caregivers and family as well as generational and cultural sensitivity. 6. Functional status and revitalization are key priorities of care
EP
Inactivity accelerates age-related declines in function. Cardiac rehabilitation, early mobilization in hospitalized patients, physical therapy and occupational therapy, out-patient rehabilitation including strengthening exercises, gait/balance, and aerobic training are vitally important to maximize function. Unfortunately, these are all under-utilized.
AC C
7. Caveat emptor for the use of evidence-based medicine in the care of older adults with cardiovascular disease Older patients are inherently at higher risk for adverse outcomes, however, the potential benefit of an intervention is often greater; therefore, age per se is rarely a contraindication to aggressive therapy. Yet, older patients, especially those with multiple chronic conditions, geriatric syndromes, and/or nursing home residence, have been under-represented in cardiovascular clinical trials; therefore, the applicability of trial findings the older population is less certain. 8. Less may be more Older patients are at risk for drug side effects, complications, and iatrogenesis. Providers should consider un-prescribing, practice slow medicine, and allow time to determine need for interventions when feasible.
ACCEPTED MANUSCRIPT
9. While you often can’t cure, don’t ever abandon
RI PT
Every technology is built for a purpose. Invasive procedures (i.e., coronary artery bypass grafting, implantable coronary defibrillator, destination left ventricular assist devices, andtranscatheter aortic valve replacement) should be undertaken for clearly defined and attainable goals of care. Even if not needing a procedure or intervention, optimal care can and should continue. 10. Palliative care and end of life discussions should be in the toolbox for care of older CV patients
M AN U
SC
Death is a certainty, yet a good death is often hard to come by. The best care considers quality of death and quality of life. Not all patients are able to discuss these issues, but avoiding the conversation risks missing an opportunity to provide better care. Palliative care can be helpful for all patients who need to choose among potentially complicated healthcare options. Helping patients, families and caregivers with these choices is at the center of health care. Goals of care can change over time, and so discussing early and during follow up is important.
References
1. Bell SP, Orr NM, Dodson JA, Rich MW, Wenger NK, Blum K, Harold JG, Tinetti ME, Maurer MS, Forman DE. What to Expect From the Evolving Field of Geriatric Cardiology. J Am Coll Cardiol. 2015 Sep 15;66(11):1286-99.
AC C
EP
TE D
2. Friedman SM, Shah K, Hall WJ. Failing to Focus on Healthy Aging: A Frailty of Our Discipline? J Am Geriatr Soc. 2015 Jul;63(7):1459-62 3. Afilalo J, Alexander KP, Mack MJ, Maurer MS, Green P, Allen LA, Popma JJ, Ferrucci L, Forman DE. Frailty assessment in the cardiovascular care of older adults. J Am Coll Cardiol. 2014 Mar 4;63(8):747-62 4. Sarkisian L, Saaby L, Poulsen TS, Gerke O, Jangaard N, Hosbond S, Diederichsen AC, Thygesen K, Mickley H.Clinical Characteristics and Outcomes of Patients with Myocardial Infarction, Myocardial Injury, and Nonelevated Troponins. Am J Med. 2016 Apr;129(4):446.e5-446.e21. 5. Quill TE, Abernethy AP. Generalist plus specialist palliative care—creating a more sustainable model. N Engl J Med 2013;368:1173–5