Hospital at Home

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                                                                                                                                   Photo credit: Shutterstock

Last week marked the annual American Geriatrics Society (AGS) meeting which brings together geriatricians and other healthcare professionals (including a growing contingent of geriatric cardiologists) to highlight the latest in research related to caring for older adults. One of the highlights was the Henderson Lecture, given by Dr. Bruce Leff (Johns Hopkins) on the future of healthcare for older adults moving out of the hospital and into the home. The general concept is that the hospital can be a disorienting environment for older adults, and there are concomitant risks (including hospital-acquired infections, falls, delirium, deconditioning due to immobility) that may be reduced by providing acute care at home. Concomitantly, cost pressures are leading health systems and insurers to think of more “out of the box” solutions to avoid the high costs associated with traditional hospitalizations.

Data on hospital-at-home models have been encouraging. For example, a meta-analysis of over 60 clinical trials in 2012 demonstrated hospital-at-home led to reduced mortality, hospital readmission, and cost. The potential mechanisms are clear: a familiar environment reduces the risk of delirium, which has multiple adverse consequences. Opportunistic infections are much less likely. Family caregivers are more immediately available to provide comfort.

Conversely, it’s clear that many of today’s hospitalized patients are too ill (and at high risk for decompensation) for acute medical care to be safely delivered at home. Within cardiology, this includes conditions that are procedure-intensive (acute myocardial infarction) or require high-level monitoring (cardiogenic shock, unstable arrhythmia). But I think many other acute cardiovascular conditions common in older adults could be managed with reasonable ease at home (mild decompensated heart failure comes to mind), provided adequate resources. Barriers to more widespread adoption of home-base models include payment for these programs (currently a work in progress), as well as the logistics of providing equipment (Dr. Leff noted in his lecture how difficult it was to deliver something as simple as oxygen).

Nonetheless, the paradigm holds considerable promise, and I’d expect health systems to adopt more of these programs in the next 5-10 years. If nothing else, changing demographics (specifically the aging of the U.S. population) will demand more innovative solutions like this.


By: John Dodson, MD, MPH

Language Matters

ashok-krishnaswamiI recently spoke at a local research conference on the topic of Geriatric Cardiology. My first slide was titled Language Matters.1    It referred to an editorial where Ms. Nancy Lundebjerg and her coauthors pointed out that the words and phrases chosen to describe older adults, either emanating from conscious or unconscious thoughts, will likely lead to certain actions. In fact, they note that the language currently used has been “an obstacle to convey to the public and policymakers the advances that have been made in healthcare and aging services.”

Furthermore, the language we choose may lead to certain biases that we develop against older adults, the possible beginnings of ageism. Ageism is an “ism”, unlike the other two, that can potentially affect all of us. Although it can be overt it is often unintentional. It refers to the discrimination against older adults “based on negative or inaccurate stereotypes”. To combat these negative or inaccurate stereotypes we must first be aware of them. I am referring to:

  • Words that have become grounded in our day to day thoughts, conversations, and actions.
  • Words that create a false imagery of aging as being only fatalistic.
  • Words or phrases that convey that this is someone else’s problem.
  • Words that editorialize the actual data in a negative manner.
  • Words such as “elderly”, or “seniors”.
  • Phrases such as “silver tsunami”, “tidal wave of aged persons or seniors”

The next step is to change our vocabulary. Some specific recommendations that were made were to:

  1. Use neutral words such as older people, older adults, older Americans (when describing persons aged 65 years and older).
  2. Be inclusive using words such as “we and us.”
    • Avoid the use of words like “aged, elder, elderly, seniors as these often have specific connotations, individual biases and negative imagery.
      • I have often attempted in my clinical encounter notes to go as far as separating the concept of chronological and physiological age by stating: “This is a female of chronological age of 85 years who has no significant cognitive disturbances, a firm social support and has intact instrumental activities of daily living and activities of daily living who presents for further management of her (name disease here).” This goes even a step further and attempts to separate the preconceived imagery based on individual biases when just stating a chronological age.
  3. Use phrases such as: “Older adults are living longer and healthier lives”.
    • Avoid the use of phrases such as “tidal wave,” “tsunami,” and similar catastrophic terms for the growing population of older adults. These phrases serve only to detract from the message and don’t point to the specific facts needed to solve the problem.
  4. In research setting use statements such as: “Our study has demonstrated that older adults had a higher incidence of a certain disease” and “We hypothesize that this is perhaps due to inadequate access to key health resources”. Then suggest improvements that can be made to completely or partially offset the problem. Explain the rationale for the finding in a positivist attitude rather than avoiding it or referring to it in a fatalistic manner.

“Language Mattersis an excellent, timely, factual, editorial that I am sure the entire geriatric and geriatric cardiology community embrace. However, a more important goal should be to disseminate this topic to our non-geriatric inclined colleagues to change the current culture and proudly display the advances that have been made in healthcare and aging services.

For further information please read the entire article that is freely available at

Other important resources in this area of appropriate language and older adults:

Lundebjerg NE, Trucil DE, Hammond EC, Applegate WB. When It Comes to Older Adults, Language Matters: Journal of the American Geriatrics Society Adopts Modified American Medical Association Style. J Am Geriatr Soc. 2017;65(7):1386-1388.


By: Ashok Krishnaswami, MD, MAS

Decision Making at the End of Life

RuthMr. M was an 89- year- old male with congestive heart failure. Over the past few weeks his dyspnea had worsened such that he could no longer lay flat and had to sleep in a chair on 6L of oxygen. He also suffered from a persistent cough that was exacerbated every time he tried to speak.

Mr. M was living at home with his wife of 67 years. They had married at 21 years of age, graduated from college, had six children and built a very successful business which they co-owned and operated for over three decades. Mrs. M faced her own physical limitations, including being primarily wheelchair-bound due to a progressive myositis. Through the challenges of life, including losing two children and the more recent physical limitations of their respective illnesses, they had become inseparable.

Mr. and Mrs. M had a nearly two-decade long relationship with their primary care doctor. He attended to them with care and compassion, even occasionally doing home-visits. On this occasion, the primary care doctor found Mr. M sitting in a chair at rest with severe exertional dyspnea. After a brief physical exam he recommended admitting him to the local community hospital for further evaluation.

While his primary care doctor was focusing on the immediate differential diagnosis—was his congestive heart failure complicated by possible pneumonia? — he did not step back and look at the big picture. Mr. M had been diagnosed with congestive heart failure eight years prior and it was clear that he was nearing the end of life. The American Heart Association has published a Scientific Statement about decision making in advanced heart failure, which includes referral to hospice in patients approaching the end of life who are not deemed eligible for mechanical circulatory support or a transplant.

As Mr. M’s granddaughter, I asked if the primary care doctor would consider hospice instead of a hospitalization. I knew that my grandparents wanted to spend their last days and hours together praying, sharing from their rich stores of memories and holding hands while sleeping. After an open conversation that took into account not just Mr. M’s physical status, but his values and wishes—primarily of which was to be with his wife and surrounded by family—Mr. M was referred to hospice. A week later he passed away peacefully, without distress and surrounded by family members who were able to come to his bedside and share meaningful last words. His last words were instructions to care for his “Queen” and to make sure that she would be given an exquisite bouquet of roses after he died.

In some of our recent work of an analysis of over 1,000 patients with heart failure in hospice, we found that the Palliative Performance Scale was able to provide an accurate prediction of death for patients with heart failure in hospice up to 90 days. This tool and others can be used to support primary care healthcare providers with making a referral to hospice and discussing end-of-life options with patients and families.

We need to shift to allowing patient values to drive the decision making at the end of life. Healthcare providers need to be more open with patients and families about palliative care and hospice services, and patients and families need to be educated to ask.


By: Ruth Masterson Creber, PhD, MSc, RN

For additional information on Palliative Care for Heart Failure patients, please visit American College of Cardiology’s blog post: Palliative Care for Patients with Heart Failure

Cardiac Rehabilitation – Effective and Underutilized

bostromTreadmills, elliptical machines, and tennis shoes; objects commonly associated with leisure time and fitness training are abundant on the 16th floor of the NYU Ambulatory Care Center, home to the NYU Cardiac Rehabilitation Program. Cardiac rehabilitation (CR) programs involve regimented, structured physical activity and are typically employed over the course of many weeks; at NYU, the standard schedule involves supervised activity three times per week for three months.

Evidence suggests that participation in CR programs after hospitalization for a variety of cardiac conditions and procedures (including stable ischemic heart disease, heart failure, and following coronary revascularization) imparts real benefits including decreased cardiovascular-related mortality, reduced hospital admissions, and improvement in health-related quality of life. ACC/AHA guidelines accordingly assign a Class I recommendation for the prescription of CR programs to patients after hospitalization for acute coronary syndrome, post-revascularization, or heart failure.

Despite these recommendations, CR programs are underutilized. Studies (here and here) have noted that many patients who could benefit from participation in a CR program are not referred upon discharge, and under-referral is even more pronounced in older patients. Given that adults over the age of 65 have the highest rates of mortality related to acute myocardial infarction and heart failure, lack of referral for these patients may represent a glaring missed opportunity for significant impact.

Notably, in a recent observational study by Flint et. al. of patients aged ≥65 with acute myocardial infarction, those with slow gait speed – a marker of frailty – were less frequently referred to CR programs. While reasons for this phenomenon are likely multifactorial (e.g. transportation, lack of available facilities, physical limitations), an important and addressable factor is referral bias; clinicians may feel that a patient who is “too frail” may be unlikely to benefit from a program that includes frequent structured exercise. Notably, in the study by Flint et al., patients with slow gait speed who participated in a CR program garnered similar benefits in outcomes (mortality, maintenance of activities of daily living) when compared their less frail counterparts. These data (which build on previous observations) suggest that even older adults who are considered frail or have significant medical comorbidities benefit from standardized referral to CR.

Initial referral is just one of many potential barriers to participation in CR programs: economic and social factors contribute to reduced rates of participation and adherence. Time commitment, including distance from home to a CR program, has also been mentioned as a barrier to utilization. In this context, mobile health (mHealth) companies are rapidly moving to develop home-based CR programs that leverage existing technologies (smartphones, tablet devices, wearable monitors) with the promise that they can serve as either a substitute or adjunctive therapy to traditional ambulatory CR programs. If successful, they may fill a significant gap in our current care paradigms for older adults by reducing a number of barriers to participation in CR programs; but rigorous trials will be ultimately required to evaluate their efficacy.

By: John Bostrom, MD

A Framework for Prevention in Older Adults

pills-1885550_960_720A recent article by Lee and Kim highlights a pragmatic approach to individualize prevention for older adults. While individualizing prevention may seem like an intuitive concept, historically many specialty society guidelines (including within cardiology) have taken a population-level approach with blanket recommendations. Anyone in practice for a few years realizes that this “one size fits all” approach falls well short in older adults, particularly when considering treatments in the setting of limited trial evidence, comorbid medical conditions, and the potential for harm.

In this context, Lee and Kim propose a simple framework to implement, based on life expectancy (LE) versus time to benefit (TTB). In their model, the intervention should be encouraged if LE > TTB, should be avoided if LE < TTB, and if LE = TTB then they advise that “the individual’s values and preferences should be the major determinant of the decision.” As a concrete example within cardiology, many trials of statins for primary prevention (the topic of a prior blog post here) have shown at least 2 years until TTB, and statins would therefore be avoided in a patient with LE < 1 year.

While predicting LE can be notoriously difficult, several risk calculators have been developed. Lee and Kim propose using, which includes risk estimates based on site of care (e.g. living at home, admitted to the hospital, living in a nursing home) and a wide range of comorbid medical conditions.

A major limitation of LE and TTB is that they are not always clear. TTB, for example, may vary widely in different clinical trials based on factors including population studied, medication adherence rates (with drug trials), and competing risks. Lee and Kim acknowledge the importance of communicating this uncertainty, as well as incorporating individual patient preferences into the treatment plan. I still find this framework incredibly useful and anticipate that risk calculators, as well as visual aids to facilitate communication with patients, will continue to be developed and improved.


By: John Dodson, MD, MPH