Cardiovascular medicine is disease oriented, technology driven, evidence rich, and focused on saving lives. Geriatric medicine is syndrome oriented, technology-avoiding, multidisciplinary, and 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.
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Cardiovascular guidelines recommend treatment based upon evidence gathered predominantly in 50–60-year-olds. While a cardiac condition may exist in isolation in younger patients, at age 80 years 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 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 are 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 sudden change in function may be the only sign of a problem. Shortness of breath may result from chronic obstructive pulmonary disease with just a mild degree of heart failure; worsening angina may result from anemia in the context of an occult gastrointestinal bleed rather than progressive coronary disease; and an elevated troponin value may reflect myocardial injury from hypoxemia in a patient with community-acquired 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 Gray 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 that influence 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
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
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.
4.Treat the Cardiac Condition in Context
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)
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
Inactivity accelerates age-related declines in function. Cardiac rehabilitation, early mobilization in hospitalized patients, physical therapy and occupational therapy, outpatient rehabilitation including strengthening exercises, gait/balance, and aerobic training are vitally important to maximize function. Unfortunately, these are all under-utilized.
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, or nursing home residence have been under-represented in cardiovascular clinical trials; therefore, the applicability of trial findings to 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.
9.While You Can't Always Cure, Don't Ever Abandon
Every technology is built for a purpose. Invasive procedures (eg, coronary artery bypass grafting, implantable coronary defibrillator, destination left ventricular assist devices, and transcatheter aortic valve replacement) should be undertaken for clearly defined and attainable goals of care. When a procedure or intervention is deemed unnecessary or futile, optimal care can and should continue.
10.Palliative Care and End-Of-Life Discussions Should Be in the Toolbox for Care
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 health care 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
- What to expect from the evolving field of geriatric cardiology.J Am Coll Cardiol. 2015; 66: 1286-1299
- Failing to focus on healthy aging: a frailty of our discipline?.J Am Geriatr Soc. 2015; 63: 1459-1462
- Frailty assessment in the cardiovascular care of older adults.J Am Coll Cardiol. 2014; 63: 747-762
- Clinical characteristics and outcomes of patients with myocardial infarction, myocardial injury, and nonelevated troponins.Am J Med. 2016; 129: 446e5-446e21
- Generalist plus specialist palliative care—creating a more sustainable model.N Engl J Med. 2013; 368: 1173-1175
Article info
Publication history
Published online: May 20, 2016
Footnotes
Funding: None.
Conflict of Interest: None.
Authorship: All authors participated in the conceptualization, generation, and approval the manuscript.
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© 2016 Elsevier Inc. All rights reserved.
