Cognitive Screening in Heart Failure

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Photo Credit: APA PsycNET

Cognitive impairment, which includes deficits in memory, language, concentration, and reasoning, is common and often unrecognized in older patients. As a trainee, one of my first projects was to work on a study that performed cognitive assessments in a series of 282 patients age >65 hospitalized for heart failure. We found that cognitive impairment was common – present to some degree in nearly half of patients – and documented by physicians in fewer than one-quarter of cases. Further, we found that cognitive impairment was associated with mortality or hospital readmission within 6 months – and that patients with impairment that was not documented by physicians constituted the highest risk group. Our findings mirrored previous studies (examples here and here) documenting the common co-occurrence of cognitive impairment with heart failure.

Translating findings like this into actionable clinical practice can be challenging, but some centers are starting to routinely incorporate cognitive screening into care. Cleveland Clinic, for example, has published findings from screening using the Mini-Cog (a simple test that involves 3-item recall and a clock drawing task) and found that an abnormal test result (indicating cognitive impairment) was the strongest predictor of readmission among 55 candidate variables. They subsequently published a protocol for training nurses to use the Mini-Cog in practice in order to facilitate implementation among clinical staff unfamiliar with the instrument.

When cognitive impairment is discovered, there’s no easy solution to management – but several strategies make intuitive sense. Involving family members more closely in caregiving — to remind patients of their appointments and to assist with medication management — may help to avoid problems related to nonadherence (for example, hospitalization for decompensated heart failure). In my own practice, I try to simplify medication regimens whenever possible in patients who are cognitively impaired, with the goal of improving adherence and avoiding adverse medication-related events. Finally, since cognitive impairment has many causes, referral to a memory center can help to establish a formal diagnosis and set expectations in terms of what to anticipate in the coming years.

 

By: John Dodson, MD, MPH

Shared Decision-Making in Acute Myocardial Infarction

Headshot_Grant_2018Several weeks ago I had the pleasure of presenting our findings from a qualitative research study we conducted at the AGS 2018 annual meeting, investigating cardiologists’ perspectives and familiarity with shared decision-making (SDM) in older adults after hospitalization for acute myocardial infarction (AMI). SDM has emerged in the literature as a way to move towards patient-centered care and has significant potential to enhance patient adherence, reduce undesired treatments, and improve overall satisfaction with care. In our study, we sought to discover the degree to which practicing cardiologists understood SDM, and whether it was applicable to their practice with older adult patients – particularly in the setting of cardiac catheterization and percutaneous coronary intervention. Five major themes emerged from these interviews:

  1. Age alone is not a major contraindication to intervention.

Our respondents consistently stated that age would not deter them from sending a patient to cardiac catheterization. Instead, they generally brought up “what kind of 80,” distinguishing chronological and biological age. Further, cardiologists generally reported treating older adults similarly to how they would treat their younger counterparts.

  1. SDM is important in the setting of NSTEMI, and not practical in STEMI:

Respondents felt that SDM was useful among patients hospitalized for NSTEMI (who represent the largest proportion of older adults with AMI). Conversely, due to the acuity of STEMI (with system-wide pressures on prompt reperfusion therapy), there was near-universal agreement that SDM was not practical in this setting.

  1. Dementia and functional status emerged as the major contraindications to intervention:

While age was not itself a major contraindication to intervention, age-related impairments such as dementia and functional status were consistently noted as reasons cardiologists would adopt a more conservative approach to care.

  1. There was some variation in cardiologists’ interpretation of SDM:

While most cardiologists saw SDM as a move away from paternalism towards patient-centered care, there was some variation in what the meaning of “shared” was among our respondents. While some respondents felt it was shared between the cardiologist and her patient, others thought it was between the patient and family members, and still others thought it was between the provider and her colleagues.

  1. A personalized (and geriatric-informed) risk calculator may help to facilitate SDM in this population for cardiologists:

Cardiologists continually highlighted the paucity of data to guide their care in the older adult population, and emphasized that a risk calculator tailored to these patients would allow them to give more specific and personalized information in order to promote SDM with accurate calculations of risk and benefit.

Our findings have several implications. The take-home message was that cardiologists generally accepted SDM as an optimal model of care, particularly in settings where the risk/benefit ratio was uncertain, but experienced some challenges with accurate prognostication. Future efforts at personalized risk calculators, tailored to older patients’ phenotypes, may help to promote SDM in practice.

 

By: Eleonore Grant, BA

Eleonore Grant was an Associate Research Coordinator at NYU Langone Health and coordinated studies on shared decision-making. She will be matriculating at medical school this Fall. 

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
https://onlinelibrary.wiley.com/doi/full/10.1111/jgs.14941

Other important resources in this area of appropriate language and older adults:
http://www.frameworksinstitute.org/toolkits/aging/
http://asaging.org/blog/developing-research-agenda-combat-ageism

Reference:
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