Elderly patients present management, treatment challenges for cardiologists
With a shift toward an increasingly elderly population, the issue of providing the best CV care for this demographic has become paramount. Further presenting difficulty is the challenge that CV issues cannot be considered in isolation in the elderly.
Approximately 19% of the U.S. population will be aged at least 65 years by 2030, and 19 million Americans will be aged at least 85 years, according to 2016 data from the American College of Cardiology’s Essentials of Cardiovascular Care in Older Adults module.
For the older population, however, CVD is often complicated by multiple comorbidities, increased surgical risk, polypharmacy and frailty. In appreciation of the coming demographic shift, cardiology and geriatrics societies have advised adoption of a more patient-centered form of geriatric cardiology.
In 2013, the American Heart Association released a scientific statement recommending a more individualized preventive and treatment paradigm for treating patients aged 75 years and older. In 2016, the AHA, ACC and the American Geriatrics Society published a statement identifying knowledge gaps in CV care for older patients.
“While there’s a strong tradition of excellence in cardiology and a tremendously proud history, aging has rarely steered the ship,” Daniel E. Forman, MD, professor of medicine in the divisions of cardiology and geriatric medicine at University of Pittsburgh and co-chair of the group that wrote the 2013 AHA statement, told Cardiology Today. “There has been a focus on diseases, on mechanisms of disease and modifying platelets, or LDL, or various other components of disease thought to determine outcomes. It’s important not to belittle those factors, but to also acknowledge that on a mechanistic level, these factors are all affected by age itself, and that beyond the mechanisms, there’s an additional notion of the patient and their individual experience.”
In many ways, the burgeoning population of elderly patients with CHD is a credit to advances in CV research and care, according to Karen P. Alexander, MD, professor of medicine and member of the Duke Clinical Research Institute at Duke University School of Medicine.
“The population we are caring for is getting progressively older in large part because of the successes in acute cardiac care 50 years ago,” Alexander said. “People are living longer, and they’re living with heart disease and other chronic conditions.”
Cardiology Today Chief Medical Editor Carl J. Pepine, MD, MACC, agreed. “We are victims of our own success, having converted heart disease to one that patents can live with, rather than die from,” he said. “But as our patients are living longer and longer with heart disease, we encounter many knowledge gaps related to this rapidly enlarging elderly population and we desperately need information from well-designed trials to help guide us.”
The improved life expectancy and overall health of older patients has led to some ambiguity over what age should be considered elderly, according to Alexander. Although age 65 years was once considered the cut-point for old age, many individuals aged 65 years today fall into a healthier, lower-risk category.
“Aging is a heterogeneous process, so there are some 65-year-olds who are probably biologically more like age 80, and some 80-year-olds who are biologically more like 65-year-olds,” Alexander said. “There isn’t a bright line with age but, in general, especially in developed nations where health is improving at younger ages, [age] 65 years doesn’t quite describe an older population at risk. A much better group to consider is patients older than age 75 or 80 years, where there are many more frail or vulnerable individuals.”
In old age, a patient begins to undergo physical changes that inherently increase the risk for CVD, according to Nanette K. Wenger, MD, FAHA, MACC, emeritus professor of medicine in the division of cardiology at Emory University School of Medicine, consultant at Emory Heart and Vascular Center and director of the Cardiac Clinics at Grady Memorial Hospital, Atlanta.
“We see multiple changes in the [CV] system with aging that actually predispose to [CVD],” Wenger, a member of the Cardiology Today Editorial Board, said in an interview. “There are changes in the arterial system, changes in the electrical system, changes in the cardiac muscle and the coronary arteries, and all of these predispose the patient to [CVD].”
Additionally, this patient population is often affected by comorbidities, which may confer iatrogenic risk and complicate medication regimens.
“These patients are particularly challenging because they tend to have multiple conditions beyond their [CV] problems, as well as other factors to consider, like frailty and cognitive decline and functional limitations,” Michael W. Rich, MD, FAHA, FACC, professor of medicine at Washington University School of Medicine, St. Louis, told Cardiology Today. “All of these things need to be considered in the care of older adults.”
The 2013 scientific statement issued by the AHA focused on the importance of individualized care in the secondary prevention of CV events in patients older than 75 years. The document emphasized the need to take into account each patient’s unique challenges, risks and functional goals when recommending treatment strategies and lifestyle changes.
“Almost no one who is older and has [CVD] has even just one [CVD] — they usually have hypertension and valve disease and coronary disease and atrial fibrillation,” Forman said. “They have multiple [CVD] but then also usually noncardiac diseases — like lung disease or arthritis. So you have these geriatric issues of multimorbidity; it’s something many physicians tend to associate mostly with their grandmothers or grandfathers, yet the disease algorithms that they apply to patients, which are ‘evidence-based,’ rarely include them.”
All too often, Forman said, an extensive and thoughtful guideline on a particular condition will only perfunctorily address the idiosyncratic features of the elderly population.
“Considering the complexity of the elderly patient, you can’t have this weighty document and then add aging at the end as an afterthought,” he said. “Aging is in every way integral to the whole thought process.”
The AHA scientific statement encourages cardiologists to have conversations with their elderly patients regarding the potential risks and benefits of all secondary prevention treatments or lifestyle modifications. According to the AHA, in elderly patients, particularly octogenarians or nonagenarians, physicians should not automatically default to survival as the main goal of a treatment plan.
“My feeling has been, for a while, that you do not ‘cure’ heart disease in older patients; it’s a chronic disease in this population,” Forman said. “So the endpoints, as I see it, have to be qualitative. One of the things I focus on is function.”
Particularly important, Forman said, is determining what the patient values most — for example, independence over a modest survival benefit — and adjusting the treatment plan accordingly.
“In a sense, cardiologists have some responsibility because we have done such a great job in helping people live longer,” he said. “They’re surviving their [MIs] because we’re doing such a good job, and now they have all these new vulnerabilities that we have, in a sense, contributed to. We need to broaden the model and treat these new aspects of disease.”
The scientific statement released in April by the AHA, ACC and the American Geriatrics Society identified knowledge gaps in the care of elderly CV patients. Gaps are largely due to the underrepresentation of older adults in the randomized clinical trials that inform CV guidelines, according to the statement. Major CV trials tend not to accurately reflect this population, due either to varying age cutoffs or strict exclusion criteria, given that patients in the community have more concurrent conditions than patients in clinical trials, Wenger said.
“Even when older patients are included in trials, these patients are different than the older patients in the community seen by practicing clinicians because of the inclusion and exclusion criteria of these trials,” Wenger said. “What we tend to see is that these patients are healthier, they have fewer comorbidities, they don’t have this characteristic elderly problem of multimorbidity, frailty and cognitive dysfunction that we often see in our communities.”
The scientific statement calls for improved recruitment of older patients for CV studies through mandatory reporting of enrollment, providing help with transportation and similar obstacles facing this population, and postmarketing surveillance. The authors recommended that efforts should be made to include geriatric patients with multimorbidity, declines in functional status and frailty.
“It is not safe to assume that the results of studies conducted in younger and generally healthier individuals necessarily apply to older adults,” Rich, chair of the statement writing committee, told Cardiology Today. “Older adults tend to be at higher risk for complications of therapies; the risk–benefit relationship tends to change with age. We have a tremendous lack of good data on what are the best treatments for older adults, especially in the context of multiple coexisting conditions, which are typically not present in the patients who are involved in clinical trials.”
He noted that the early trials of transcatheter aortic valve replacement, as well as the subsequent PARTNER trials, are an exception.
“The early TAVR studies specifically included a high-risk, older population who had aortic stenosis and were considered too sick or otherwise not suitable for surgical [AVR],” he said. “Those patients in the early TAVR trials and the PARTNER studies were typically in their early to mid-80s, with a good number [older than] 90 years, so that has been an exception to the general rule.”
With the overall lack of accurate representation of the elderly population, the guidelines that result from these studies are often similarly flawed, experts said.
“The problem that we see is that these patients have outlived their evidence-based guidelines,” Wenger said. “This population is not represented in the clinical trials that form our evidence base for all of the therapies that we do.”
The issue of frailty
With the increase in aging patients — particularly those aged at least 80 years — frailty also has become a mounting concern. According to Alexander, frailty is less a consequence of any particular health condition as it is a consequence of aging.
“Frailty is a phenotype,” she said. “The older person is slowing down, they’re having more falls, they’re losing weight, their energy is lower, maybe their appetite has decreased. It’s something that is intrinsic to the older population, and it’s relevant to how well they do with interventions and procedures.”
According to Forman, elderly patients with CVD are particularly vulnerable to frailty.
“It has been well documented that because of inflammation, because of the mechanisms that underlie [CVD], frailty is more likely to happen to cardiac patients,” he said. “This is important. Older patients with [HF], or [peripheral vascular disease] or coronary disease, they’re all more likely to become frail.”
To provide patient-centered care, taking frailty into account is an essential piece of the puzzle, Rich said.
“It’s important to identify those patients who are frail and recognize that these people are at higher risk for poor outcomes,” he said. “This is essential in communicating with the patient and the family about the likely outcomes and the likely risks of a major procedure and how these factors can be addressed.”
Forman said he also considers the influence of frailty when advising patients on lifestyle modifications.
“The thing I’m focused on, as many are, is the question of whether exercise can help,” he said. “This can be counterintuitive because most patients who are frail don’t get referred to cardiac rehab. They’re told to just ... sit in their chair, which really just makes it worse. So what I’m assessing is whether the patient can do exercise, what kind of exercise, what is realistic in helping that patient recover from their [CVD].”
Cognitive, functional issues
Equally important in assessing the elderly CV patient is understanding the patient’s functional status and cognitive function, Wenger said.
“We still don’t have good metrics for many of the geriatric features,” she said. “Some of the scores for CV surgery have some measures, the EuroSCORE uses mobility, and one of the other scores basically has surrogates for frailty, but none of them measure functional capacity, none of them measure cognition, and these are extremely important because the lower the functional capacity, the higher the risk for adverse outcomes, including fatality.”
Cognitive impairment can interfere in patients’ ability to understand their condition and in their ability to keep up with what often amounts to a long list of medications, Alexander said.
“Increasingly, it’s concerning that these patients may not remember to take their medications, or may take medications in ways that are not intended,” she said. “The ability to support them is not specific to cardiology care as much as to their overall care. We’ve all seen patients coming back where it’s obvious the ball was missed, that they didn’t understand what was being asked of them.”
Additionally, a patient’s cognitive function should be considered in determining the scope of treatment goals, Rich said.
“The cognitively impaired individual is likely to have a shorter life expectancy, and so interventions that don’t have payoff in the short term may be less valuable in a cognitively impaired person,” he said. “Aggressive [BP] control is one example. Overly aggressive [BP] control in this population has not shown clear benefit and may be associated with worsening cognitive function and increased risk for falls.”
As elderly patients begin to experience the multifaceted struggles of old age, they are tasked with keeping track of increasingly complicated medication regimens, many of which are for morbidities unrelated to CHD. Wenger said physicians must communicate with other specialists, and must keep track of a patient’s medications at every point of care.
“Any time a physician sees an elderly patient, they should look at their medication list and talk about deprescribing because, particularly in a hospital setting, so many drugs may be given for a transient problem, but they never get removed from the list,” Wenger said. “Also, different physicians may prescribe the same category of drug, and the patient is essentially taking two different drugs that basically act the same way.”
Each care transition should be treated as an opportunity to review and possibly streamline medication regimens, according to Wenger.
“The reconciliation of medications at every care transition is important: from home to hospital, from [ICU] to step-down units, to either rehab or nursing home and then back to home,” she said.
Pepine said his team is doing this frequently in practice. “I am deprescribing or cancelling my fellows’ and physician’s assistants’ orders regularly,” he said. “If a 92-year-old, who has been hypertensive most of her life, wants to stop all her antihypertensive medications because she believes that she has accomplished what she calls ‘successful aging’ and ‘doesn’t need pills any longer,’ maybe she is correct. Should we be treating to goal for life, or should we be treating them at all?”
Ongoing cooperation from a patient’s family at home also is essential, Alexander said. “Communications with the pharmacies through electronic health records has helped; nursing that goes over the medication list at every visit helps,” she said, “but ultimately, someone to organize things in the home environment is what is needed.”
Rich said these issues will be addressed at an ACC/American Geriatric Society/National Institute on Aging workshop scheduled for February 2017 on pharmacotherapy in the aging population.
“The workshop will develop ideas toward, ultimately, formulating a research agenda on how future studies can address these very issues: medication prescribing in older adults; deprescribing or eliminating longtime medications that patients don’t need any longer,” he said.
An accurate picture
Moving forward, one of the key goals for CV geriatric care is to more accurately represent this population in clinical trials.
“A number of us have addressed the FDA regarding the importance of representing this population,” Wenger said. “If we’re going to market a drug or treatment to an elderly population, the FDA should probably require that these patients be represented in the design of the study.”
Besides prioritizing better-designed trials, geriatric cardiology must move toward caring for each patient based on the patient’s unique challenges and goals, Forman said.
“Geriatric cardiology includes these notions of trying to coordinate, trying to communicate and trying to tailor care,” he said. “That sometimes means maybe backing off some things that are guideline-based by other standards, but not just doing it haphazardly; doing it with intentionality.” – by Jennifer Byrne
- Fleg JL, et al. Circulation. 2013;doi:10.1161/01.cir.0000436752.99896.22.
- Rich MW, et al. J Am Coll Cardiol. 2016;doi:10.1016/j.jacc.2016.03.004.
- For more information:
- Karen P. Alexander, MD, can be reached at 2400 Pratt St., Durham, NC 27710; email: firstname.lastname@example.org.
- Daniel E. Forman, MD, can be reached at University of Pittsburgh, Section of Geriatric Cardiology, 3471 Fifth Ave., Suite 500, Pittsburgh, PA 15213; email: email@example.com.
- Carl J. Pepine, MD, MACC, can be reached at Cardiology Today, 6900 Grove Road, Thorofare, NJ 08086; email: firstname.lastname@example.org.
- Michael W. Rich, MD, FAHA, FACC, can be reached at 660 S. Euclid Ave., Campus Box 8086, St. Louis, MO 63141; email: email@example.com.
- Nanette K. Wenger, MD, FAHA, MACC, can be reached at 49 Jesse Hill Jr. Drive SE, Atlanta, GA 30303; email: firstname.lastname@example.org.
Disclosure: Alexander, Forman, Pepine, Rich and Wenger report no relevant financial disclosures.